Glyndŵr University
Glyndŵr University Research Online
Social Inclusion Research Unit
Social and Community
3-1-2009
An Evaluation of the All-Wales Dietetic Capacity
Grant Scheme: Final Report
R Carnwell
Glyndwr University, r.carnwell@glyndwr.ac.uk
Sally-Ann Baker
Glyndwr University, s.baker@glyndwr.ac.uk
Odete Parry
Glyndwr University, o.parry@glyndwr.ac.uk
Lynne Kennedy
Glyndwr University, l.kennedy@glyndwr.ac.uk
Emily Warren
Glyndwr University, e.warren@glyndwr.ac.uk
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Copyright 2009 Authors, Glyndwr University and the Welsh Assembly Government. his is research
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Recommended Citation
Carnwell, R., Baker, S., Parry, O., Kennedy, L., and Warren, E. (2009), An Evaluation of the All-Wales Dietetic Capacity Grant Scheme:
Final Report, Wrexham: Glyndŵr University
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An evaluation of
The All-Wales Dietetic
Capacity Grant
Scheme:
Final report
Report Prepared for the Welsh Assembly Government
March 2009
Project team:
Prof. Ros Carnwell
Director of Centre for Health and Community Research
Sally-Ann Baker
Senior Lecturer, Centre for Health and Community Research.
Prof Odette Parry
Head of Social Inclusion Research Unit
Dr Lynne Kennedy
Senior Lecturer, Centre for Health and Community Research
Emily Warren
Research Assistant, Social Inclusion Research Unit
P if sgol Gl dŵ W e sa
Gl dŵ U i e sit W e ha
Ffordd yr Wyddgrug, Wrecsam, Cymru. LL11 2AW.
Mold Road, Wrexham, Wales. LL11 2AW.
Ffon/Tel: +44(0)1978 293170
Ffacs/Fax: +44(0)1978 290008
r.carnwell@glyndwr.ac.uk
s.a.baker@glyndwr.ac.uk
Contents
Executive Summary: An evaluation of the All-Wales Dietetic Capacity
Grant Scheme
1)
Introduction and background ............................................................................................ v
2)
Aims of the evaluation ...................................................................................................... vi
3)
Project characteristics...................................................................................................... vii
4)
Findings ............................................................................................................................ vii
a)
Organisation and delivery of initiatives and courses .................................................. viii
b)
What course participants valued................................................................................. viii
c)
Key messages learned ................................................................................................. viii
d)
Evaluation of courses .................................................................................................. viii
e)
Partnerships and benefits.............................................................................................. ix
f)
Impact of programmes .................................................................................................. ix
i)
The organisational level............................................................................................. ix
ii)
The course participant level ...................................................................................... ix
iii)
The community level .............................................................................................. x
g)
5)
Key success and challenges ............................................................................................ x
i.
Evaluation of projects – successes ............................................................................. x
ii.
Evaluation of projects – difficulties/challenges......................................................... xi
i)
Future plans .............................................................................................................. xii
Recommendations for future sustainability .................................................................... xii
a)
Strategic ........................................................................................................................ xii
b)
Early years, schools and community settings ............................................................... xii
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
An evaluation of The All-Wales Dietetic Capacity Grant Scheme: Final
report
1
Introduction and background ........................................................................................... 1
2
The all Wales dietetics capacity grant scheme ................................................................. 5
2.1
Ethics ......................................................................................................................... 6
2.2
Aims of the Evaluation............................................................................................... 7
2.3
Evaluation design....................................................................................................... 7
2.3.1
Impact evaluation .............................................................................................. 7
2.3.2
Formative process evaluation ........................................................................... 7
2.4
3
4
Training and networking events ................................................................................ 8
Data collection methods ................................................................................................... 8
3.1
Minimum data sets .................................................................................................... 8
3.2
Data collection within case studies ........................................................................... 9
Findings ............................................................................................................................. 9
4.1
Organisation and delivery ......................................................................................... 9
4.1.1
Project characteristics ....................................................................................... 9
4.1.2
Project staffing................................................................................................. 10
4.2
Delivery of training .................................................................................................. 10
4.2.1
Non-accredited training................................................................................... 11
4.2.2
Accredited training .......................................................................................... 11
4.2.3
Practical cookery skills ..................................................................................... 15
4.3
Working in partnership............................................................................................ 16
4.4
Involvement with other initiatives .......................................................................... 20
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
4.5
4.5.1
Impact at the organisational level ................................................................... 24
4.5.2
Impact on course participants ......................................................................... 26
4.5.3
Impact at the community level........................................................................ 32
4.5.4
Impact on ea l
4.5.5
Impact on schools ............................................................................................ 39
4.5.6
I pa t o
4.5.7
Impact on snack provision ............................................................................... 41
4.5.8
Impact on community members ..................................................................... 41
4.6
ea s setti gs ........................................................................ 36
ate i g fo looked afte
hild e ................................................ 40
Evaluation of projects and successes and challenges ............................................. 46
4.6.1
Successes ......................................................................................................... 46
4.6.2
Challenges........................................................................................................ 50
4.7
5
Impact of projects.................................................................................................... 24
Long term sustainability .......................................................................................... 57
4.7.1
Meeting the needs of nutrition education in nurseries and schools .............. 57
4.7.2
Resource implications...................................................................................... 57
4.7.3
Long term roles................................................................................................ 60
Discussion of key findings ............................................................................................... 62
5.1
Delivery of initiatives and courses ........................................................................... 62
5.2
Partnership work ..................................................................................................... 63
5.3
Supporting and developing other initiatives ........................................................... 63
5.4
Impact of programmes ............................................................................................ 63
5.5
Organisational (strategic) impact ............................................................................ 64
5.6
Impact on course participants ................................................................................. 64
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
6
5.7
Community impact .................................................................................................. 65
5.8
Successes and challenges ........................................................................................ 65
Conclusion and recommendations ................................................................................. 68
6.1
Recommendations for future sustainability ............................................................ 70
6.1.1
Strategic ........................................................................................................... 70
6.1.2
Early Years, schools and community settings.................................................. 70
References ............................................................................................................................... 72
Appendix 1: FlowChart ............................................................................................................ 77
Appendix 2 - Minimum data set proforma .............................................................................. 78
Appendix 3 - Evaluation questionnaires used by Dietitians .................................................... 96
Appendix 4 - Different models of course delivery ................................................................. 115
iv
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Executive Summary: An evaluation of
the All-Wales Dietetic Capacity Grant
Scheme
Professor Ros Carnwell, Centre for Health and Community Research
Professor Odette Parry, Social Inclusion Research Unit
Sally-Ann Baker, Centre for Health and Community Research
Dr Lynne Kennedy, Centre for Health and Community Research
Emily Warren, Social Inclusion Research Unit
1) Introduction and background
The Welsh Assembly Government launched its Food and Fitness – Promoting Healthy
Eating and Physical Activity for Children and Young People 5 Year Plan in 2006. As part of
the implementation of this plan a grant scheme was launched to increase dietetic
capacity to inform and support communities in healthy eating. The scheme will run until
2011 and targets the 0 to 25 age groups.
The aims and objectives of the grant programme are to:
Increase the capacity of dietitians in Wales to inform and support communities in
healthy eating through:
Facilitating with appropriate training (on local or regional basis) the incorporation of
nutrition into the work of other people working with groups of children, young
people and or families in the community e.g. youth workers, Sure Start, Flying Start
workers, care workers.
and/or
Increasing the number of local people appointed to work with groups of children and
young people in the community on food and nutrition issues, through employment
as community food workers, with appropriate professional supervision.
Support local action in response to the Food and Fitness Action Plan for Children and
Young People.
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The main key performance indicators of the scheme are:
a) The effective delivery of accredited OCN1 level 1 and 2 community food and nutrition
courses
b) Developing partnerships with other agencies and influencing established
partnerships
c) Supporting other community food and health initiatives that contribute to the food
and fitness action plan
This do u e t epo ts the s he e s e aluatio a d o e s the pe iod of epo ti g data
from 31st November 2006 to October 1st 2008. A community based formative
evaluation and an impact evaluation was conducted during this time.
2) Aims of the evaluation
The aim of the evaluation was to assess the impact of the grant scheme in increasing the
capacity of dietitians in Wales to inform and support communities in healthy living.
The objectives were to:
i)
Assess the feasibility of enhancing the current provision of food and nutrition
services to address health determinants, to include the introduction of
community food workers2 and training key professionals working with
communities
ii) Assess the effectiveness of the grant scheme at the organisational level (i.e.
dietitians, other professionals and community workers involved in service
delivery), including building knowledge, developing skills, engaging with the
1
The OCN is part of the National Open College Network (NOCN), one of the main national awarding
bodies in the U.K. The OCN accredits nationally recognized learning programmes. In Wales, OCN Food
and Nutrition Skills courses are studied at 3 Levels. Level 1 OCN is comparable to NVQ Level 1, GCSEs
D-G and Foundation Diploma. Level 2 OCN is comparable to NVQ Level 2, GCSEs A-C and Higher
Diploma. Level 3 OCN is comparable to NVQ Level 3, A and AS Levels, Advanced Diploma.
2
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community, developing networks and delivering interventions addressing health
determinants
iii) To assess the effectiveness of the grant scheme at community level, including
increasing access to food and nutrition services, building knowledge and
changing behaviour (e.g. food purchasing patterns, cooking skills and food
consumed).
3) Project characteristics
As at the end of September 2008 there were 10 programmes across Wales. To date 12 out of
13 potential programmes are running of which 10 were able to be included in the evaluation
phase.
Recruitment difficulties impacted upon the project start dates and although 5 projects
started as planned in October/November 2006, 6 were unable to start until 2007. Three
projects were being run by a single dietitian, although most projects employed 2 or more
staff. Data collection and sample
All programmes collected a minimum data set. In addition, a case study approach involved
visits to four case study areas, conducting a total of 31 interviews with 87 individuals, project
staff and course participants. The latter came from a wide range of workplaces including:
community food workers, schools, early years and child care settings, youth and community
services and public health. Most course participants had completed or were currently
studying Level 2 Open College Network (OCN) courses. Some participants wished to go on to
use their expertise to deliver Level 1 OCN courses.
4) Findings
The findings are organised around the key performance indicators of the grant scheme
(delivery of OCN community food and nutrition courses; development of partnerships; and
supporting other community food and health initiatives) as well as the objectives of the
evaluation – assessment of the impact of the scheme at the individual, organisational and
community level.
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a) Organisation and delivery of initiatives and courses
One of the key roles of the Community Dietitians was the delivery of OCN courses. By
September 2008, 135 accredited courses had been provided, 124 at OCN level 2 and 11 at
OCN level 1. Since commencement, 1280 participants had enrolled on an OCN course with a
92% completion rate, and of these 84% achieved an OCN Level 1 or 2 pass.
b) What course participants valued
Participants valued several features of the OCN course including: the qualification and its
value to future job prospects; the structure of the sessions, adaptation, course materials and
homework; and networking opportunities arising from the mix of professions present.
Participants learned an immense amount of information, and were confident in
disseminating this in their work.
c) Key messages learned
Key messages from the course included what constitutes a balanced diet and its importance,
the need to reduce sat and sugar intake, food labels, oral health and nutrition, nutritional
needs through the life course, vitamins and minerals, hydrogenated fats, 5 a day, and portion
sizes.
d) Evaluation of courses
Dietitians used a number of strategies to evaluate the courses they delivered, including
attendance records, course evaluations and questionnaires. These revealed that most
successful parts of the OCN course included its flexibility and responsiveness and application
to participants themselves. Once the course was completed, following participants up in
their work settings was also a great success. The main difficulties identified by dietitians
related to a lack of resources (mainly staffing), which affected their capacity to deliver OCN
courses and to follow up participants; and resistance from staff in schools and nurseries,
sometimes due to personal preferences and sometimes due to budgetary constraints.
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e) Partnerships and benefits
Ninety-three separate partnerships existed at the end of phase 1 (2006 to 2007); most of
these were maintained throughout the duration of the project and by September 2008, 184
separate partnerships were recorded. Most were local multidisciplinary partnerships with
public sector and voluntary organisations. The benefits of partnership work included
implementation and delivery of strategies and action plans in relation to promotion of
nutrition.
Partnership work enabled dietitians to develop a strategic role and to inform policies on
nutrition, as well as to become involved in many different initiatives run by other
projects/organisations, often in an advisory capacity. Their expertise was invaluable in
advising on menus, oral health, and other initiatives requiring nutritional input. Dietitians
also participated in community-based and school and college health events to promote
healthy eating messages. Involvement with other initiatives provided dietitians with
networking opportunities to further promote the availability of the OCN Food and
Community Nutrition and other courses, thus enhancing recruitment.
f) Impact of programmes
The impact of the grant scheme was evident at three different levels – the organisational
level, the course participant level and the community level.
i) The organisational level
Much of the organisational impact resulted from partnership working, with partnership
alliances increasing throughout the duration of projects. Nutritional expertise of project
dietitians was drawn upon widely across partnerships at a strategic level, and dietitians were
enabled to access target groups within their organisations and networks. Partnerships also
enabled understanding of local needs and specific services, which in turn led to sharing of
information and good practice across multidisciplinary networks. Sharing of information also
led to a more strategic approach to the delivery of training in order to avoid duplication
across boundaries and to ensure effective support of course participants and delivery of
nutrition messages in the community.
ii) The course participant level
Responses to questionnaires distributed by dietitians revealed that 94 percent of course
participants had acquired new learning from the course, including information about a
balanced diet, and salt and sugar intake. Eighty-five percent intended to or already had
changed their behaviour, including healthier, more balanced, diets with fewer snacks, eating
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more regularly or having breakfast, and purchasing and cooking of fresh food. Course
participants also shared information with family members, resulting in changes in family
eating behaviours, as well as changing their behaviour in their workplace as a result of their
increasing knowledge and confidence. As a consequence, they influenced changes in menus
and eating behaviours in early years settings, schools and after-school clubs, youth clubs,
and other community settings.
iii) The community level
At the community level, partnerships enabled the actions of strategies to be delivered. This
resulted in enhanced nutritional awareness and improved cookery skills in communities,
early years settings, schools and colleges as well as better access to nutritional information in
the community and a greater range of nutritional resources being available for community
events. All this impacted on the eating behaviours of parents and families through cascading
of information and development of skills.
Course participants were also influencing the communities they worked with, such as preschool providers, schools, hospitals and the community. Changes in these settings included
ha ges i
hild e s s a ks a d d i ks, ooki g egi es a d e ipes to fa ilitate health
eating. Teachers were including nutrition in schemes of work and children were becoming
increasingly involved in School Nutrition Action Groups (SNAGs) and were taking
responsibility for influencing school menus. There was, however, some resistance on the
part of nursery and school staff, some of whom did not want change, and dietitians
increasingly worked to combat this throughout the life of the project with increasing
success.
Course participants also influenced the eating habits of relatives and provided explanations
about food to young people. As a result, shopping habits had changed, food labels were
read, and some had changed their approach to food with meals being planned and healthier
cooking methods adopted.
g) Key success and challenges
The overall evaluation of the grant scheme programme revealed a number of successes and
challenges.
i. Evaluation of projects – successes
The OCN course was very successful. Good progress was made in reaching target groups,
whose knowledge and confidence increased, resulting in changes in eating behaviour and
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information being passed on to the communities with whom they work. Dietitians were
proactive in sharing resources with course participants, enabling them to disseminate
information further. There was increasing emphasis on work in community settings and the
success of SNAGs, Get Cooking and some similar initiatives. Innovative ways of growing
vegetables were also reported.
ii. Evaluation of projects – difficulties/challenges
Lack of resources was the main challenge for project dietitians. Dietitians lacked capacity to
deliver OCN courses and follow up course participants in the community following
completion. The workload involved in moderation of courses was also demanding and
moderation was often slow. Difficulties were also reported due to the lack capacity to
deliver Level 1 OCN courses and lack of availability of Level 33 courses. Level 1 courses had
been developed and Level 3 courses were being piloted during September 2008. The delay in
the development of these courses was due to them not being part of the Dietetics Capacity
Grant Scheme. Course participants also had difficulties arising from resource capacity due to
demands of other roles, such as curriculum demands or budgetary constraints. These
demands led to resistance in some staff.
Course participants, having completed the course, also faced the challenge of influencing
parents within a culture of heavily marketed processed foods, so that lifestyle barriers were a
major influence.
3
Level 3 OCN Community Food and Nutrition Skills is designed for those who have completed the
Level 2 course, who wish to deliver Level 2 under supervision, but do not have the appropriate
teaching experience. It covers topics from community mapping to facilitation and teaching skills to
enable learners to further their knowledge of community nutrition to support their delivery of Level 1
OCN courses.
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i)
Future plans
Dietitians and course participants alike had many plans for the future, which would extend
e o d the life of the g a t s he e. Dietitia s pla s i ol ed tea hi g Le el
OCN a d
supporting and monitoring course participants once they had completed. They also intended
to strengthen existing partnerships and to work with various initiatives, including SNAGs and
the Snack Award Scheme, Flying Start, allotments and Fun with Food. Course participants
were also developing new roles as they developed confidence. Their future plans included
supporting a range of community food initiatives incorporating food growing, food co-ops,
mentoring, training volunteers, and expansion of OCN Level 1 to develop practical skills.
5) Recommendations for future sustainability
From the evaluation and reflective comments of participants interviewed a number of
recommendations can be put forward to ensure sustainability of the programmes and
continued impact long term. These are as follows:
a) Strategic
Recognise and utilise the public health role of dietetics on a permanent basis.
Develop a network of trainers to deliver training.
Consider making the OCN in food and nutrition a required qualification, particularly
i ea l
ea s setti gs a d s hools.
Consider appointing more school nurses - if one school nurse was attached to each
school this would make a considerable impact.
Ensure nutritional education is included in the school curriculum.
Provide training for teachers in food and nutrition.
Provide long term monitoring and support to ensure consistency of nutritional
messages in the future.
b) Early years, schools and community settings
Develop the role of Community Food Workers further to include delivery of OCN
Level 1 courses, provision of cooking skills classes, and work with community
initiatives, such as allotments and food co-ops.
Educate children from an early age, and ensure an environment that promotes
uptake of healthy food and drinks.
Embed healthy eating into the school curriculum, and include children in this process
through involvement in SNAGs.
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Recruit support workers as core staff as an ongoing process and with appropriate
supervision.
Provide ongoing support to community staff on changes to nutrition policy and
promote further development and monitoring of such work.
Integrate food and nutrition across different services, thereby facilitating a change
of culture around food.
Continue development of OCN courses through Levels 1 to 3 to enable cascading of
delivery throughout the community.
Increase partnership to ensure consistency of nutrition messages from people in
different fields and to integrate initiatives. This would include closer links between
health and education, and between nurseries and schools in relation to nutrition.
xiii
An evaluation of the All-Wales
Dietetic Capacity Grant Scheme
1
Introduction and background
It is widely accepted that diet-related ill health creates a considerable burden on individuals
and society (Department of Health (DH), 2004; SACN, 2003; WHO, 2003). Concerns over
rising levels of obesity in the population, and the social and economic burden associated
with overweight and obesity is also a major public health issue (DOH, 2007). In the UK, as in
other Western industrialised societies, policy makers agree that public health can be
improved through dietary changes at the individual and population level.
The two major causes of premature mortality in Wales are currently heart disease and
cancer. A link between heart disease, Type 2 diabetes, certain cancers and poor diet is
widely acknowledged; according to the Welsh Health Survey (2005/6) only 42 percent of
adults in Wales eat the recommended five portions of fruit and vegetables a day (Welsh
Assembly Government, 2007). As poor dietary habits among adults are passed onto children,
the impact of diet-related ill health is passed from generation to generation (Robinson and
Elliot, 2000; Neumark-Sztainer et al ., 2003). Lifestyle behaviours developed in childhood are
also more likely to develop into adult lifestyle behaviour (Kelder et al .,
; hild e s
lifestyle behaviour is formed early in life (Dennison et al., 1998) and is more malleable than
adults
eha iou Si ge et al., 1995). There is clearly a need for public health interventions
aimed at improving both the type and amount of foods people in Wales eat on a regular
basis (Food Standards Agency and Welsh Assembly Government, 2003).
It is known that widening inequalities in health correlate with socio-economic status, leading
to unequal opportunities to take-up a d sustai health eati g p a ti es O Neill et al.,
2004). Indeed, as a group low income households in the UK are less likely to consume a
healthy diet (Department of the Environment Food and Rural Affairs DEFRA, 2001; FSA,
2002) and experience the greatest burden of diet-related ill health and disease (DH, 2003a;
Office of National Statistics ONS, 2001). Hence there is a clear mandate within all UK public
health policies, including Wales, for action to ameliorate social inequalities in health
including improvements to diet (DH, 2004; WAG, 2007).
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Historically, the main strategy for effecting dietary change in the UK has focused largely on
persuading consumers to change dietary behaviour through nutrition education; whereby
the emphasis is clearly placed on individual lifestyle and responsibility, relying on the
successful dissemination of healthy eating advice, usually from a professional, as the main
vehicle for influencing behaviour change. Although as recent dietary trends suggest,
improvements have been made, this is far from universal, with increasing health and
nutritional inequalities between socio-economic groups (DH, 2003b). Research consistently
demonstrates that low income households find it difficult to adopt healthy eating guidelines.
Contrary to popular belief, this is to do with economic and circumstantial barriers, such as
lack of income, poor access to food and shops, inadequate storage and cooking facilities, not
ignorance of healthy eating messages (DH, 1996; Dowler & Calvert, 1995; Kennedy & Ling,
1996; NFA, 1997).
Despite this recognition, attempts to influence dietary behaviour have not changed much
over the years. More recent approaches involve the use of social marketing to tailor
nutrition education to the socio-cultural needs of lower socio-economic groups (DH, 2008)
a d the de elop e t of lo al food i itiati es su h as
ook a d taste o
Food Co-ops
(Caraher & Cowburn, 2004; Dowler, 2000; Dowler & Caraher, 2003) .
As a more client-centred approach to behaviour change, participants are shown how to
implement guidelines under difficult financial circumstances. As some critics argue however,
this approach fails to address the structural causes of food poverty: lack of money and
access to food. Moreover, as previous work demonstrates this kind of approach is labour
intensive and therefore costly to implement, reaching only limited numbers (Kennedy et al .,
1998). This is echoed in the findings of ‘o
t ee s national study into Community Food
Projects (McGlone et al., 1999), which concluded that although worthy, most local
community food projects only reach a small proportion of the target population and are
rarely sustained beyond initial funding.
Dietary behaviour, like any other health-related behaviour, is complex and in order to
ha ge people s eati g patte s a i te -disciplinary, multi-factorial approach is needed. The
WHO framework for a health promotion approach (WHO, 1986), recognises that health is
related to social, cultural and structural factors in addition to biological and psychological
factors.
This approach recommends changing the physical and social environment to
facilitate lifestyle change. Despite this framework, there is only limited evidence that a wider
2
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understanding of health promotion and the necessary practical experience has been
achieved. This could weaken the potential impact of community initiatives.
Within public health it is widely recognised that policy and organisational support are
important prerequisites for successful health promotion; policy developments aimed at
removing or reducing the broader economic and structural barriers to dietary change,
although instrumental to success, are however only a relatively new concept in the UK (DH,
2004). Thus, practitioners working in the field must continue to find ways of developing, and
evaluating, innovative and effective alternatives to reach communities in need of their
support. The task of identifying and improving ways to influence and improve dietary habits,
particularly amongst the so- alled ha d to ea h is the efo e a halle ge for dietitians and
other professionals working in this area.
Evidence suggests the most effective interventions to improve dietary practices have been
settings-based (Roe, 1997). Many intervention programmes based in community settings,
which tackle specific health-related behaviours (including diet), have been part of wider
initiatives tackling cardio- as ula disease o
a e O Loughli et al ., 1999; Brownson et
al., 1998; Tudor-Smith et al ., 1998, COMMIT Research Group, 1996; Carleton et al ., 1995;
Goodman et al ., 1995; Luepker et al ., 1994; Rossouw et al ., 1993; Farquhar et al ., 1990;
Puska et al ., 1976). Most of these programmes have utilised some form of community
organisation to form partnerships with their communities. While there has been extensive
research on the effectiveness of partnership working (El Ansari, 1998; Gillies, 1998), few
studies have explored obstacles to and facilitators of the successful implementation of
specific programmes in communities from the perspective of both service deliverers and
participants.
As Kennedy (2001) notes from a 10 year community nutrition initiative based in Liverpool, as
part of the European multi-city Food and Shopping Research Project (Vaandrager et al .,
1993; 1995), despite the laudable efforts of policy makers and practitioners in public health
to advocate approaches based on intersectoral collaboration and community participation,
success in translating these into practice is still limited and relatively costly (Kennedy, 2001).
Furthermore, where implemented, the true meaning of these principles and the effort
involved in securing genuine community involvement and partnership working is
considerable. Both the benefits and costs involved in undertaking genuine community
partnership working tend to be underestimated.
3
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Moreover, this is rarely acknowledged by key policy makers or those who control funding.
Frontline staff therefore constantly challenge traditionally narrow interpretations of health
promotion in the community setting and the dominant paradigms of health and disease
(ibid, 2001). As a result many community-based initiatives designed to address dietary issues
and promote healthy eating are in danger of being assessed against traditional values and
criteria.
Although community development approaches to implementing health-related initiatives
are increasingly advocated, there is a paucity of data available to inform the process of
successfully engaging communities in health promotion initiatives directed at behaviour
change (Robertson & Minkler 1994). Indeed, factors affecting the use and usefulness of
community development approaches remain poorly understood despite an identified need
to develop and disseminate knowledge of community development approaches for health
practitioners (Ritchie et al ., 2004; Laverack, 2001; Laverack & Wallerstein 2001; Robinson &
Elliott 2000; Labonte, 1998; Labonte, 1994; Israel et al ., 1994; Bernstein et al ., 1994; Bracht
& Tsouros 1990). Initiatives based upon community participation and partnership working,
although clearly advocated within public health, is complex, time consuming and therefore
costly to implement (Kennedy, 2001).
In the UK, Community Dietitians have increasingly turned to what are now referred to as
Community Food Initiatives (CFI), as a broader response to diet-related problems of
communities and in particular of lower socio-economic groups or the so- alled ha d-toreach (BDA, 2005; Caraher & Cowburn, 2004; Dowler, 2000; Dowler & Caraher, 2003).
Evidence, albeit limited, suggests certain types of CFIs provide more socially and culturally
relevant alternatives that successfully engage with communities and may also facilitate
dietary change with the so called ha d to ea h e.g. DoH,
; A de so et al ., 1996;
Anderson, 2007; Moynihan & Hyland 2004). Professional-led community food initiatives
(CFI), however, are time-consuming and costly to deliver (Kennedy et al ., 1998; 1999). Policy
makers, service managers and practitioners, therefore, continue to seek cost-effective
alternatives.
One such option involves the recruitment of lay health workers to assist professionals in
undertaking the more semi or un-skilled aspects of their work. Lay health workers are
indigenous to the communities they serve and perform functions relating to disease
p e e tio o health p o otio a d
ell ei g,
ith spe ific focus on food and public
health; trained in some way in the context of the intervention; but having no formal
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p ofessio al o pa ap ofessio al ualifi atio s Ke
ed ., 2008). Their primary role is to
encourage dietary change by translating complex messages into credible and culturally
appropriate advice (Kennedy & Milton, 2008).
Whilst the value of lay health workers is acknowledged (indeed some community dietetic
assistants within the current programme may be lay people), the current initiative has
focused on the training in food and nutrition of professionals who are employed to work in
the community with children and young people and the scheme is intended to incorporate
more nutrition and health into their work. Funding was made available through the scheme
to employ Community Dietitians in each of the NHS Trusts in Wales to promote a consistent
nutritional message across Wales.4
2
The all Wales dietetics capacity grant scheme
The current initiative, which provides support to NHS Trusts in Wales, aims to:
Increase the capacity of dietitians in Wales to inform and support communities in
healthy eating by:
o
Facilitating, with appropriate training (on local or regional basis) the
incorporation of nutrition into the work of other people working with groups
of children, young people and or families in the community e.g. youth
workers, sure start workers, care workers.
and/or
o
Increasing the number of local people appointed to work with groups of
children and young people in the community on food and nutrition issues,
through employment as community food workers, with appropriate
professional supervision.
Support local action in response to the Food and Fitness Action Plan for Children and
Young People (See Appendix 1).
4
In the current study the term Community Food worker is used to denote those who work in the
community, and deliver food and nutrition as part of their role (Youth Workers, Communities First,
fitness instructors et …)
Community Dietetics Assistant is be used to describe community food workers who are employed to
support the dietitians
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The main key performance indicators the scheme are:
The effective delivery of accredited OCN5 level 1 and 26 community food and
nutrition courses
Developing partnerships with other agencies and influencing established
partnerships
Supporting other community food and health initiatives that contribute to the food
and fitness action plan
This is a flexible approach which, while recognising the importance of community
involvement/development, also acknowledges that interventions will require sufficient input
from those trained in nutritional issues (Press and Mwatsama, 2004). Because the
programme design incorporates a service delivery oriented and a community-based
approach, it requires a reflexive and sensitive evaluation strategy. For this reason a
community-based formative evaluation was conducted, whereby themed findings from an
initial data collection round were fed back to service providers prior to a final data collection
phase which also captured the perceptions/experiences of service recipients at the
community level.
The current document reports the evaluation of the first 2 years of the scheme, reporting
data from 31st November 2006 to September 30th 2008.
2.1 Ethics
Advice was taken from the Wales OREC Manager. As an evaluation project NRES ( National
Research Ethics Service) MREC ( Multi-site Research Ethics Committee) approval was not
required and ethical approval was gained from the Glyndwr University Research Ethics
Committee (GREC).
5
Open College Network
6
Level One; comparable to NVQ Level 1, GCSEs D-G and Foundation Diploma. Level Two; comparable to NVQ
Level , GCSE s A* to C a d Highe Diplo a. Le el Th ee; o pa a le to NVQ Le el , A a d AS Le els, Ad a ed
Diploma
Source: National Open College Network http://www.nocn.org.uk/learners/qualification-levels-and-equivalences
: accessed 2/4/09
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2.2 Aims of the Evaluation
The aim of the evaluation was to assess the impact of the grant scheme in increasing the
capacity of dietitians in Wales to inform and support communities in healthy living.
The objectives were to:
Assess the feasibility of enhancing the current provision of food and nutrition
services to address health determinants, including the introduction of community
food workers and training key professionals working with communities
Assess the effectiveness of the grant scheme at the organisational level (i.e.
dietitians, other professionals and community workers involved in service delivery),
including building knowledge, developing skills, engaging with the community,
developing networks and delivering interventions addressing health determinants
To assess the effectiveness of the grant scheme at community level, including
increasing access to food and nutrition services, building knowledge and changing
behaviour (e.g. food purchasing patterns, cooking skills and food consumed)
2.3 Evaluation design
The study used a combination of impact and formative process evaluation methods.
2.3.1 Impact evaluation
As the study was concerned with identifying the impact of the grant scheme at different
levels, an instrument to collect minimum data was designed by the evaluation team and
project dietitians. Dietitians used this tool to record activities and outcomes from their
programmes. The
i i u
data sets a isi g f o
this
e e ollated and analysed by the
evaluation team.
2.3.2 Formative process evaluation
The study was informed by formative process evaluation, incorporating a case study
approach. As formative evaluators the research team worked interactively with
stakeholders, and the process was action-orientated, rather than conclusion-orientated
(Patton, 1986). The process evaluation involved looking at how programmes were
produced. This required more than a description of the programme and their intended
effects; rather it explored how programmes changed over time so that the context was
provided within which to interpret outcome measures (Patton, 1986).
It was expected that given the community-based thrust of the intervention there would be
substantial scope for the emergence of unanticipated programme benefits, or other
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outcomes. Some programme outcomes may be indirect and as such not obviously
attributable to the programme. In addition, some outcomes may develop in the longer term
and therefore not emerge until several years later. It was important therefore for the
evaluation to be reflexive in its interpretation of the findings, in order that any future and
unintended outcomes of the programme could be captured.
2.4 Training and networking events
Each programme project was trained in methods of routine data collection to enable them
to collect data on project performance. To this end two events focusing on project
evaluation were held, to which representatives from each project were invited.
3
Data collection methods
Qualitative and quantitative data were collected over 2 phases, phase 1 covered the period
2006-2007, and phase 2, 2007-2008. Methods employed included the compilation of
minimum data sets and case study interviews/group discussions conducted in four case
study areas (Table 3.1). The latter were purposively selected to represent the geography
and demography of Wales. North and South Wales were represented as well as areas of
different population density (urban/rural) and industrial heritage (e.g. mining, coastal).
Variations in levels of deprivation were also reflected.
Table 3.1 – Data sets
Phase One: November
Phase Two: November 2007
2006 –October 2007
to September 2008
11
12
Dietetics professionals
4 interviews (n=13)
4 interviews (n=11)
Course participants (inc
9 interviews (n=35)
14 interviews (n=28)
Minimum data set
Case Study Interviews
community members in phase 2)
3.1 Minimum data sets
Minimum data set proformas (MDS) (Appendix 2) were developed in conjunction with
project dietitians.
The
i i u
data set was split into 4 sections and collected
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information about the delivery and organisation of the project, the impact and perceptions
of training, impact on the community and personal reflections.
To feed into the MDS, a set of evaluation questionnaires were developed with and for the
dietitians to aid data collection from training participants and community members
(Appendix 3).
3.2 Data collection within case studies
Data were collected by in-depth interviewing of community food workers, key professionals
trained in food and nutrition as part of the scheme, dietitians, dietetic assistants and
community members. Interview questions focused on: nutrition knowledge acquired by
trainee and dietary information transmitted by dietitians; number of workers trained;
number and nature of partnerships developed with other programmes; how community
workers addressed determinants of health; action taken to engage hard to reach groups;
efficiency and effectiveness of the delivery of community food and nutrition services;
changes in access to food and nutrition services; examples and evidence of changes in food
purchasing patterns, cooking skills and food consumed.
4
Findings
The findings reflect the views and experiences of dietetics professionals, course participants
and community members and are organised around 6 themes – organisation and delivery,
working in partnership, involvement with other initiatives, impact of projects, evaluation of
projects and successes and challenges, and long term sustainability.
4.1
Organisation and delivery
4.1.1 Project characteristics
Projects were set up October 2006 – mid 2007 depending on the recruitment of project
dietitians. As at the end of September 2008 there were eleven projects funded through this
grant scheme across Wales in the following areas: Neath Port Talbot, Swansea (Abertawe
Bro Morgannwg University NHS Trust), Merthyr Tydfil, Pontypridd and Rhondda (Cwm Taf
NHS Trust), Gwent (Gwent Healthcare NHS Trust), Pembrokeshire and Derwen,
Carmarthenshire (Hywel Dda NHS Trust), Conwy and Denbighshire, Wrexham and Flintshire
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(North Wales NHS Trust), Cardiff and Vale (Cardiff and Vale NHS Trust). 7 Projects are based
within NHS trusts, NPHS or within LHBs
4.1.2 Project staffing
At the time of reporting, three projects were being run by a single dietitian but most projects
employed two or more staff and eight were supported by dietetic assistants. Over the
course of the evaluation there were a number of changes in staffing. Between 2007/2008
two dietitians left - one vacancy had been successfully filled, whilst the other was in the
recruitment process. Changes to support staff also occurred in a few projects.
4.2 Delivery of training
An important element of the grant scheme is the delivery of consistent food and nutrition
messages in the community with an emphasis on the delivery of the OCN (Open College
Network) Level 2 Community Food and Nutrition Skills to food and community workers who
will cascade the information in their own organisations. More recently cookery skills courses
ha e ee added to the po tfolio. A o di g to dietitia s efle ti e o
e ts this has ee
an important development:
The rolling out of OCN Level 1 practical Cookery course by our Project Support
Worker has completed a streamlined and seamless stable of training
packages designed to equip learners to cascade information into a wide range
of Health and Social Care settings.
In response to an identified need a Level 3 course is currently being piloted to run alongside,
to enable successful participants deliver OCN level 1 Food and Community Nutrition in the
community. Attendance at Level 3 courses will therefore be the natural next step for many
of those who had completed Level 2 in Community Food and Nutrition.
Between November 2006 and September 2008, 220 separate training events/courses were
recorded. Around 7,000 individuals received training (accredited and non-accredited) or
attended an event delivered by the dietitians (for some community events no figures were
provided due to the difficulty in obtaining such data and the figure is likely to be
substantially higher).
7
Three areas have struggled to recruit a dietitian since the start of the scheme, however two of these
have since managed to recruit and these projects are now operational
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As the projects became embedded in the community the number of participants increased,
and during 2006/2007 around 2012 individuals were trained or had contact with the
projects. This increased to over 4,947 in 2007/2008. Training delivered was categorised as
a
edited a d o -a
edited a d this a ti it is des i ed i the follo i g su se tio s.
4.2.1 Non-accredited training
Eighty-five non-accredited training events were recorded; these comprised a wide range of
activities from school health days, smoothie and healthy lunch box sessions, to growing
schemes, cook and eat, nutrition seminars and training for sports centre staff, school cooks
and governors etc, one-off sessions on topics such as food labeling, and the eatwell plate,
and additional top up sessions in for example, child nutrition at the request of OCN
participants.
Many of these activities were run as part of other initiatives, and were more likely to involve
community members, such as school children, and parents. For example in one case study
area they delivered basic nutrition sessions in private gyms, often focused on correcting
erroneous information given to people in the gym or one-off sessions such as with learning
support assistants.
4.2.2 Accredited training
The delivery of OCN accredited food and nutrition courses has been one of the priorities of
the grant scheme in increasing nutrition capacity across Wales and further details of the
delivery of these courses is outlined below.
4.2.2.1
Courses delivered
By September 2008, 135 accredited courses had been run, 124 at OCN level 2 and 11 at OCN
level 1 (Table 4.1.). Whilst the majority of courses delivered were Community Food and
Nutrition Skills, other variants were also delivered. In the first 2 years of the scheme 1280
had enrolled on an OCN course and (at the time of reporting) 1180 had completed8 . Drop
out from courses was low (n=40, 3.1 %), with non-completion mostly being due to illness or
employment commitments.
8
60 had not finished as their course was still running
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Table 4.1. - Number of Accredited courses delivered by course title
Type of course
No.
OCN Community food and nutrition skills
95
OCN Community food and nutrition skills for early years Level 2
16
OCN level 1 practical cooking skills
10
OCN Nutrition and Healthy Catering in Schools
11
OCN Confidence to Cook Level 2
1
OCN Community food and nutrition skills for early years Level 1
1
OCN Promoting health to young people Level 2
1
4.2.2.2
Pass rates and progression
Pass rates were good and 993 achieved an OCN Level 1 or 2 pass, this figure does not include
participants from 28 courses whose files are yet to be moderated (an issue which will be
discussed at a later point in the report). A small number of community members however
who attended a course elected not to submit portfolios, having undertaken the course for
their own interest.
4.2.2.3
Delivery models employed
Most participants had to find time in their working lives to attend a course. To accommodate
this and facilitate recruitment, dietitians developed a range of delivery models. OCN food
and nutrition Level 2 courses were either 10, 12, 20 or 30 hours in length and delivery of the
courses varied widely from delivering modules over 3 consecutive days, to one day or
session per week (Appendix 4). Similar variance in delivery was noted for Level 1 courses;
these were between 10 and 12 hours in duration and were delivered over a number of
weeks, either in two-hour, half day, or full day sessions.
4.2.2.4
Course participants
The main target groups for OCN training were people working in the community with the
under 25s pa ti ula l
ith hild e
a d s hools,
ith after-schools
oki
easi g. As
can be seen from Table 4.2, a wide range of different groups attended the OCN courses, and
a range of professions and organisations were represented including volunteers and
o
u it
e
e s. The e
as a o ti ui g de a d fo
ou ses fo community workers
a d health p ofessio als o ki g ith fa ilies a d ou g hild e . This was considered to
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be partly due to the increased awareness of the benefits of the OCN training within partner
organisations.
The OCN i Co
o
u it food
u it Food a d Nut itio Skills Le el
is a popular course among
o ke s a d is becoming the recognised course to attend in order to
progress any nutritional projects in their work (dietitians reflections). In at least one area,
the course was embedded in the Nutrition Action Plan; almost all health visitors and school
nurses had attended and there was a waiting list. In another project area, family services
required all health visitors, school nurses and midwives to be OCN trained by 2010-2011:
whilst in another locality, nursery nurses who support health visitors (e.g. with homeless
people and in deprived areas) were required to do the course.
In another area there was a drive towards local generational work and nutrition was
recognised as one of the key areas. As it was evident that staff needed to do the OCN
course, they were targeted through the health and wellbeing network. Some case studies
targeted parents, people working with children (e.g. school and play workers), other groups
(e.g. a church group), and food technology teachers. Food technology teachers were
o side ed to e the ideal people to do the Level 2 because they could then deliver the Level
as pa t of the u i ulu
within schools.
Table 4.2 - Range of groups attending accredited training
Groups attending accredited training courses
Carers and looked after children professionals
Child minders, early years, play professionals and advisors
Community project workers
Dietetics assistants and community food project Workers
Housing and return to work professionals
Local authority employees
Out of schools hours clubs and youth organisations
Parents, community members and volunteers
School health, health promotion, health and public health professionals
School pupils and peer mentors
School, leisure, hospital and community caterers
Sports development, PE, leisure and fitness professionals
Teachers and community education tutors
4.2.2.5
Course recruitment
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A number of recruitment methods were used to enlist appropriate people onto courses.
These included distributing posters and phoning local contacts in schools, colleges and other
people worki g
ith hild e . O e dietitia
as also trying to get into the college to do
hild a e t ai i g a d ate i g t ai i g . Dietitians regularly recruited by visiting local
g oups o atte di g
eeti gs
du i g
as o side ed
eeti gs. This
a ea a d the e a
ith lo al o ga isatio s a d flaggi g up the OCN ourse
e so e o fusio
ost effe ti e e ause there is a lot going on in the
ega di g
hat
e e offe i g - it may be confused
ith so ethi g else . A dietitian in one case study also planned to do a presentation to local
head aste s
eeti gs a d dis uss i itiati es ith the .
In another case study the food safety officer took responsibility for recruiting nursery staff
because she inspected the food safety of all nurseries – 16 nurseries were thus recruited.
Typically, throughout the case studies, people heard about how valuable the course was
from colleagues and then made contact themselves, so word of mouth was an important
recruitment method. One dietitian had 10 ready for the next course purely through word of
outh, a d did ot ha e a e ue et. Dietitia s efle ti e o
e ts also eite ated that
word of mouth had led to an increase in demand for the OCN course:
All the organisations are starting to realise the OCN course provides the basis
for ensuring that accurate, consistent food and health messages are
promoted to schoo- aged children. At a recent nutrition sub group meeting of
the healthy schools network a visiting health professional commented that
there were noticeable benefits of having a qualified dietitian on board.
Circulating flyers and emailing schools and clubs also resulted in recruitment of 10-15 on
each course in one case. One dietitian also recruited through dietetics contacts:
We e i tou h ith the ai dieteti depa t e t so if there are initiatives
they want us to take part in locally we channel that through our contacts.
So eti es the e i te ested i the ou se itself a d othe s the e i te ested
in delivering certain topics or to a specific client group, so I say I can either
meet up with you and we can discuss ways that you can approach it or I can
de elop lesso s fo ou a d just assist. O e the e got the a e o es it s up
to the to deli e it. So eti es the e o e alo g to hat a out deli e i g
stuff, then the e ealised ho little the k o a out ut itio , the all of
sudden they decide they should come on the course, so I reel them in that
way.
In this same case study, dietitians discussed their target groups at monthly meetings,
including how to tap into other local initiatives or what is going on politically in the area.
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That s ho
e got i ol ed i leisu e se i es. We fou d out it as a hot topi fo WAG a d
so dis ussed ho
e ould tap i to it . This dietitian had phone calls from local people who
had seen the posters advertising the OCN course and wanted to attend and bring their
relatives. She explained that the course was for health and other professionals who then
deliver the messages to the public.
It was evident that recruitment needed to target specific groups, which respondents
sometimes found difficult. One dietitian, for example, had queries from nurses regarding
how to encourage older people to eat and had to explain that their target group was under
25s. They did, however, offer some resources and a place on the course if there was one
free.
Overall, dietitians were successful in reaching their target groups for courses and attendance
was generally good. Only one person had dropped out in each of three case studies for valid
reasons. Two case studies reported having waiting lists.
4.2.3 Practical cookery skills
An important development was the delivery of practical cookery skills courses and there was
the recognition that nutritional information could be cascaded through the community if
supported with practical food preparation skills. One case study reported that these had
been delivered in schools and were to commence in the community in September 08, with
the help of three support workers and two peer leaders. The dietitians in this case study also
enthused about the imminent development of the OCN Level 1 course, which will focus on
community food and nutrition skills:
The Level 1 theory based courses will be really useful. A lot of those resources
a e si ila , ut the e s ot so u h e ui ed - games and activities and
participatory, so it will work well with practical skills.
In another case study, a Level 1, one-day practical cookery skills course was offered to
anyone who had done the 30 hour OCN course:
Two people from every school signed up and this was co-ordinated by
education. I just had to be there on the day to tie the nutrition activities to
health essages a ou d the food e e hose to ook. Health isito s also
attended this course and then introduced basic cookery within their local
community centres. Between the Level 1 OCN and the food hygiene and the
day when they do cookery, they do 12 different dishes and we sit down and
eat a d the off the go ith
e ipes a d that s the e ipes the follo .
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4.3 Working in partnership
Partnership working was seen as key to the success of the grant scheme, in raising its profile
and the role of Community Dietitians and in conveying consistent nutritional message across
Wales. Alliances could be with individuals, other initiatives, and organisations as well as with
other departments within the project organisation. The findings reveal that dietitians were
proactive in developing partnerships, with either those already in existence or were
developing new relationships in the first year of the scheme, with 93 separate partnerships
being recorded. Most of these partnerships were maintained and further partnerships
developed, with 184 separate partnerships being recorded by September 2008.
Nineteen partnerships were considered useful to the project, in providing direction, or
working with a project operating on either an all-Wales or regional basis. The latter included
the OCN Wales, Community Dietitians in Wales Group, Welsh Assembly Government
Appetite for Life, Cardiac Dietitians group, Corporate Health Standards Schemes, Healthy
Schools Scheme, National Pharmaceutical Association and partnerships formed with the
other dietetics projects.
The
ajo it
operating
of pa t e ships, ho e e ,
areas,
with
97
such
e e lo al pa t e ships,
partnerships
existing.
ithi
These
the p oje ts
include
multi-
agency/multidisciplinary partnerships and those with individual organisations, departments
or initiatives (see Table 4.3). Typically, dietitians worked closely with a number of different
organisations. In one case study, for example, there were links with nurseries, as well as with
food safety and public protection services. The fire service had also contacted them with a
view to integrating them into their practical cookery initiatives. The local Healthy Living
Partnership was also strong in this area and was planning generation work locally. As one
case study respondent indicated:
I was in a meeting where they championed nutrition and the OCN course as
one of the top 3 priorities that they want to do, so that s goi g to take pla e
within the next 2 years.
In another case study, partnership working was enabled by their office location within a
public health team, which facilitated discussion:
We e al a s shouti g a oss the oo , oh that ould e good for my
p oje t, o ou ight a t to feed i to this . It ight e so ethi g s all like
they need information for the Healthy Schools scheme, or advising them on
diffe e t leaflets the a take i , o Get Cooki g. ... We do t k o a out all
the policies and things that are out in the community, things like Health and
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Well ei g St ateg ,…I e pi ked up so u h a out poli ies a d st ategies a d
ho to ite the …a d ho to li k i … a d the politi s, a d I ould t ha e
ee a a e of all that if I had t een in the office within public health.
Respondents in another case study were based in Local Health Board offices which also
e a led pa t e ship o k. This had fa ilitated deli e
of t ai i g to the e te t that training
by the Project team is being mainstreamed into the strategic plans of a number of Health
a d So ial Ca e setti gs agai st eeds a al sis .
Table 4.3 Examples of local multidisciplinary/multi-agency partnerships
Health Alliances
Acute and community
LHBs
Local Public Health Teams
Oral Health
School Nursing
Education
Early Years
Primary
Secondary
Adult education
CPD teams
Sure Start
Flying Start
County Council/ Local Authorities
Leisure services
Sports development
Healthy School
Environmental Health
Social Services School Meals Service
Libraries
Youth and out of Schools services
IT departments, Human Resources
Regeneration, nurseries, play
schemes, community/voluntary
organisations
Communities First, Food Co-ops
Such partnerships enabled dietitians to contribute to a number of strategic groups, 42
partnerships having a strategic function (Table 4.4). In some of these, dietitians had a key
role in developing local strategy, policies and standards. In addition, 93 partnerships existed
for the purpose of implementing and delivering strategies, and action plans and
development of further initiatives and training. A number of the new partnerships identified
had a quality assurance function, and partnerships with OCN bodies had been formed for the
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purpose of ensuring that there was a sta dardised, consistent approach ...taken in the
desig , deli e
a d
o ito i g of OCN Cou ses .
Table 4.4 Functions of different partnerships
Function of
partnership
Strategic
Implementation
of strategy or
action plan
Example
Nutrition Strategy and Action Groups
Physical Activity and Nutrition group
Appetite for Life Group
Cymru Cooks
Health and Wellbeing Implementation Group
Peer Training Programme
Schools Menu and Marketing Group
Gold Standard Snack Award
Way of Life Lottery Bids
Early Years Food and Health Strategy
National Public Health Service.
Local secondary school and alliances to drive forward various initiatives
Gold S a k A a d S he e
Development of healthier menus in early ea s settings
Delivery of nutrition awareness sessions
Development of t ai i g pa kages, toolkits a d othe esou es
Respondents in a case study area described a strategic partnership in which they worked
with the local public health department, which was tasked with putting the Nutrition
Strategy together, based on a health promotion approach:
The e s a a tio pla … a d fo u s, -7, 8-25 and adults [representing] a
ide a ge of o ga isatio s… a d it does gi e a li k the e. We e uildi g
li ks o
ith leisu e se i es ith the lo al autho it . We e looki g at
health e di g a d e e ha i g a e leisu e o ple lo all .
It was evident that the partnerships formed through CDiW (Community Dietitians in Wales)
and with other professionals and projects had a supportive function. They enabled projects
to keep up to date with developments, provided opportunity for peer review and
opportunities to share and develop good practice. Case study data revealed that contact
with other dietitians was important for those new in post. One explained how, when first
appointed, she visited other areas to see what they were doing and then subsequently
maintained contact with them. They gave ideas on progressing Level 1 OCN and one offered
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to contribute to the pilot of the Level 3 OCN course. Although not directly part of the grant
scheme, the development of the OCN Level 3 course was being shared across the dietitians
in Wales depending on their expertise and was an important means of maintaining contact
across Wales. The pilot was being planned for September 2008 with a view to rolling it out
across Wales. I South Wales e e al ead got uite a fe people li ed up a d g oups that
the
e ead to o k ith a d deli e Le el
ith .
Many partnerships (138) were used by dietitians to promote the food and nutrition project,
OCN training and to provide a forum to facilitate information exchange and gain access to
target groups. For example, many of these partners actively marketed and recruited for
OCN courses whilst others provided facilities and networks required for course delivery.
Most projects linked with other members of dietetics teams to draw on their specialist
expertise or to keep them informed of developments and initiatives in the community. An
i po ta t li k
as
ith paediat i se i es, due to dietitia s
ai
e it being with 0-25s
and particularly with early years:
We e ot spe ialised e ough to e a le to sa that hat e ad ise is t
going to contradict anything in the Trust, so I would then liaise with the
paediatric dietitian, either to run things past her to make su e the e o e t.
One dietitian was planning to work with one of the paediatric dietitians if the MEND9
p og a
e goes ahead a d
he
Happ Health Futu es o
e es. Paediat i t ai i g
was also being planned:
Project dietitians are to do recom e ded paediat i t ai i g… so that she a
gi e app op iate ad i e to health p ofessio als… The health isito s ha e
been on our courses as well and instead of going back to paediatric dietitians,
we link in with them.
Award and launch events similarly were organised by partners to ensure the widest
dissemination of activities, and partnerships with past course participants were formed.
Ensuring partner organisations were well informed about the project enabled partners to be
proactive in promoting the course and the recruitment of course participants, but also
9
Mind, Exercise, Nutrition... Do It: a structured education programme for young children and their
families to support weight loss
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resulted in the dietitians gaining greater knowledge and strengthening working
relationships.
4.4 Involvement with other initiatives
In addition to the courses, training and partnerships already described, project dietitians
reported involvement with a wide range of projects and organisations. These include
Healthy Schools Schemes, Cymru Cooks, Gold Standard Snack Scheme, MEND, Big Lottery
funded projects, Oral Health, Youth Services, nutritional standards groups, workplace health
groups, County Council and Local Authority departments, Local Health Boards, National
Public Health Scheme, health inequalities and other community projects, schools, colleges,
universities and after-school clubs. Levels of involvement included advice and input to aid
the development of other initiatives and resources, participation in health events,
promotion and recruitment to OCN courses, the delivery and planning of nutrition education
(and cooking skills), impact assessment, implementation of local policy and networking.
The availability of Community Dietitians provided initiatives/organisations with a ready
resource for specialist nutritional knowledge, thus ensuring their involvement in a range of
initiatives (Table 4.5).
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Table 4.5 Range of dietitians' involvement in initiatives
Advice:
analysis of nursery menus
content of oral health leaflets, healthy lunch boxes, nutrition information leaflets and menus
ut itio al sta da ds i se o da s hools a d ea l ea s setti gs
Input to:
training of school governors
development of school, after-school and community cookery packages
hild e s fit ess i itiati es
nutrition information website
weaning DVD
Development of further initiatives:
School Nutrition Action Groups
Gold Standard Snack Award
Cymru Cooks
healthy tuck shop resource pack
peer education package for after-school clubs
healthy lifestyles scheme for 8-11 year olds
visual resources and teaching aids for primary schools
resources for school nurses
cookery schemes
Participation in community and work-based events:
events to promote healthy eating
school and college health events, e.g. practical cooking skills, healthy packed lunches at parents
evenings, practical weaning skills sessions.
Nutritional input to training:
INSET for secondary and primary school teachers
Cymru cooks
oral health training
ea l ea s p ofessio als
Youth Workers.
Projects were very active in early ea s setti gs. So e e e i ol ed i the Gold Sta da d
S a k A a d,
hi h
as o iginally developed in Caerphilly, but is now being run or
developed in 6 project areas in conjunction with other organisations and alliances. Training
and guidance is given to early ea s settings to increase awareness of the need to consider
the provision of healthier catering to pre-school children and receive consistent nutritional
essages. Su essful s he es a e a a ded the Gold Sta da d Snack A a d fo p o idi g
healthier foods and promoting healthy food messages to staff, children and parents.
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Dietitia s efle ti e o
e ts highlighted the i po ta e of the award event for the Early
Years Nutrition Project:
Everyone was there from the partners, the links with education at the
fou datio phase. The ele ato e e t ought it all togethe … a d people
could see how what they could do would fit into other areas of the curriculum
– creative development, gross motor skills, digging in the garden. There were
g eat e a ples of hild e pai ti g ith a sp i g o io spo ta eousl .…It s
already reaching 1,000 hild e th ough
g oups, so e e got so e uite
big nurseries on board.
This su ess as o
e ted o fu the i the dietitia s efle ti e o
e ts, i
hi h the
reported continuing support from partner organisations represented at the Early Years
Childcare and Development Partnership (EYDCP):
Other organisations are including the scheme in their future plans
demonstrating greater commitment at all levels to ensure childcare settings
provide an environment for infants and young children which promotes
optimum physical health through good nutrition practices. The EYDCP has
already agreed to fund award packs for groups achieving the award by July
2009 demonstrating their continued support for the scheme.
Contact with early ea s settings was also apparent within case study data, with 16
nurseries being involved to date in one case study. One case study was developing a cook
ook ith a u se
hi h i luded all the recipes we tested and then the next stage will be
rolling that out and offering it to hild a e se i es . Another case study had links with Wales
Play Groups Association, National Child Minders Association and National Day nurseries
Association, as well as CSIW:
The CSIW isit the setti gs a d k o a out the s he e a d if the e a a e
that the setti g has the gold sta da d the k o that the e et the
standards and that it contributes to the quality within that setting.
Case study respondents were also delivering healthy eating advice sessions to Flying Start
health visitors and were working with projects such as Happy Healthy Future (targeting
nutrition and physical activity to under 5s), and Appetite for Life. The latter included training
some teachers in OCN Level 2 so that they could meet the Appetite for Life targets within
the curriculum:
We have people from health promotion, schools, the voluntary sector, nursery
staff, pla
o ke s… Oral health in the nurseries, health promotion, and
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environmental health, as well as a few technology teachers based in
education.
The impetus then continued with school-aged children and projects were proactive in
developing School Nutrition Action Groups (SNAGs) in Secondary Schools across 7 project
areas. The SNAG toolkit developed in the first phase of the scheme was adopted by the
Welsh Assembly Government to cascade through Wales. Involvement with SNAGs, although
time consuming, had a number of benefits including: strengthened links with catering and
schools, enhanced interagency working, and fostering of good relationships within
educational settings and parents. School staff are nominated to run SNAGs within their
locality, which also ensures sustainability. Within these settings young people are
encouraged to contribute their ideas, and changes within schools have been identified as a
result of the initiative, such as the availability of healthier options and pupil led taster
sessions.
Work with other initiatives then extended beyond school age. One case study, for example,
linked with an after-school organisation, which enabled dietitians to access school children
both in and out of the school:
Th oughout the su
e I doi g eekl ooke sessio s i su
e s hool
lu s a d o e of those is goi g to e a high s hool usi al. Be ause I ha e t
got a support worker I have to do a lot more of the p a ti al stuff, ut I e
been invited in to do some cookery sessions as well, to boost the confidence of
pla o ke s ho a e al ead doi g it…, ea h su
e lu ill ha e a health
da a d… I ll do health s a ks a d health lu h.
Links with Cymru Cooks (a Welsh Assembly Government initiative designed to encourage
young people to develop cookery skills) were also prominent. Dietitians have been involved
with 8 projects funded through this scheme at a range of levels from their launch, the
development of a cookery toolkit, and actively supporting the projects through the provision
of OCN level 2 training for the trainers and nutrition events in schools and local
communities.
Typically, projects would be involved in a wide range of initiatives. Initiatives changed rapidly
though and it was necessary to target people working on whatever initiatives were taking
place, which was often difficult to predict:
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Thi gs ha ge all the ti e so it s diffi ult to ite a p oje t pla fo hat e ll
be doing for 2010, because other things will be going on. We have to link in
with things as they happen.
Multi-disciplinary meetings (including local authority members) also took place as part of the
links with different initiatives, which enhanced opportunities for training:
We e dis o e ed lots of oles ithi the Lo al Autho it that e did t k o
e isted efo e … A lot of the
a e o the t ai i g…We e t ai ed leisu e
e t e staff a d …de elop e t offi e s fo the ug tea , ho go ou d
schools and promote physical, but they now do nutrition as well.
Association with these and other initiatives has increased awareness of the dietetics
projects, strengthened the networks of the dietitians, forged links at a strategic level and led
to improved partnership working with the organisations involved. This then enabled the
cascading of training and the delivery of consistent nutritional messages and approaches to
a range of recipients.
Commenting on the value of working in this way, one case study respondent indicated that:
I the past e e al a s had to sa e e thi g is i g-fe ed a d e e o e s
stretched to the limit. But now if someone wants support for a health
promotion event we can liaise with them so that they get the right message.
Previously people with no nutritional knowledge may be giving advice and
e e ot ee a le to he k hat s ee said, he eas o people o e to
us for support.
4.5 Impact of projects
Impact of the projects was assessed at three levels, the organisational, participants and
community. Figure 4.1 models the cascading of Food and Nutritional knowledge and its
resultant impact on course trainees and community members.
4.5.1 Impact at the organisational level
Much of the organisational impact resulted from partnership working and as discussed in
section 4.3 these had a number of functions (Table 4.6). Partnerships were enabling the
actions of national strategies to be delivered, such as those stipulated in the Nutrition
St ateg fo Wales Do u e t Food & Well ei g a d Appetite fo Life , Food and Fitness, as
well those defined in local nutrition strategies and policies. Project dietitians were better
able to respond to local need and target training appropriately and get feedback on the
quality of training delivered, and how the knowledge was being used within organisations
and the community.
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Sharing knowledge, skills, ideas, resources and best practice were frequently cited as a
benefit, for example, dietitians were able to draw on the specialist knowledge of other
professionals. This sharing of i fo
atio , ho e e ,
as a t o
a st eet , a d the
contributions made led to a raised awareness of diet and nutrition projects and the role and
expertise of Community Dietitians. This e a led p oje ts to get o the age da , to e
included in local plans, inform strategy and policy (such as Local Nutrition Strategies and
Appetite for Life) and promote a consistent nutritional message.
Partnerships led to enhanced understanding of local needs and also of specific services, such
as school meal services, health promotion and other initiatives, in addition to the needs of
specific groups. This formation of partnerships appeared to benefit projects in a number of
ways; they provided support and guidance, improved links with other initiatives and
facilitated further access to target groups and settings. In addition, partnerships aided
recruitment, the delivery of nutrition training and the dissemination of consistent nutritional
information at a local level.
Knowing what was available locally and being aware of what other dietetics projects were
doing impacted positively on projects. This p e e ted the ei e tio of the
heel and
enabled the sharing of resources and good practice with other initiatives and projects, such
as the Gold Sta da d Healthy Snack A a d S he e , pee edu ation projects in schools and
Fu
ith Food . Mo eo e , sha i g of i fo
atio a d pa t e ship o ki g also esulted i
the joint development of training courses (such as the development of an OCN Level 3
Community Food and Nutrition Skills qualification), packages, toolkits, leaflets and other
initiatives.
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Table 4 6 - Impact of partnership working on the community (Rank Order)
Delivery and availability of nutrition information in schools and the wider community
Enhanced Nutritional awareness
Access to training/ More people trained in community
Improved dietary provision in schools and pre- schools, Hospital, Youth clubs
Confidence to deliver nutritional information
Shared/ availability of resources
Delivering Actions of Nutrition Strategy
Developed nutrition group, policy or other initiative
Planned provision/Potential for Level 1 course to be delivered
Tackling chronic disease and obesity
Needs analysis
Potential to access hard to reach
Support
Improved awareness re: equality issues
Joined up approach
110
29
24
22
12
11
11
10
9
5
2
1
2
1
1
4.5.2 Impact on course participants
Dietitians assessed the impact of the OCN courses on participants through post course
questionnaires (see appendix 3). By September 2008, 1281 post training questionnaires
were distributed, 1207 were returned (a 94% response rate). A total of 381 follow-up
questionnaires were distributed, yielding a 52% (198) response rate.
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
OCN
OCN participants
from range of
settings
Learning
Evidence that learning leads to
attitude and behavioural
change. Information being used
in home
Evidence of changes made to menus, and
foods provided in a variety of settings.
Information being used at work
Evidence of nutritional information being passed on to
community members
Evidence of dietary changes being made within the home,
healthier choices being selected, more care when shopping,
cooking rather than processed foods.
Figure 4.1 Evidence of information cascade and attitudinal and behavioural change
4.5.2.1 Learning acquired
The findings revealed that 94% (1209) of course participants had acquired new learning as a
result of attending the course. Respondents were asked what they believed to have been
the most important lessons learnt. As can be seen from Table 4.7, learning about a balanced
diet and its importance were the most frequent responses. Other responses included the
need to reduce salt and sugar intake and making sense of nutritional information on food
labels. Further (less frequent) responses indicated an increased awareness of oral health and
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nutrition, the different nutritional needs through the life course and the importance of
vitamins and minerals.
Table 4.7 Most i po ta t lesso s lea t f o
the ou se f o
the pa ti ipa ts pe spe ti e
(Frequency of response in rank order)
Importance of balanced diet
Understanding reducing salt sugar, fats
Food labeling
Effects of diet on health
Stages of weaning and early years nutrition
To eat more fruit and vegetables
Nutrition in across the lifespan
Importance of vitamins and minerals
Effects of media and advertising
Everything
Oral health
Promotion of healthy eating messages
Portion sizes
Resources and sources of information
Understanding fats and the need to eat unsaturated
Ease of healthy eating
Eating on a budget
302
140
133
53
36
30
29
24
20
17
13
10
10
8
6
3
3
Often participants in case study interviews (including school nurses and nursery staff)
reported being amazed at how much they did not know about food and how much they had
learned about the content of food and food labeling.
One of the key messages mentioned by participants was the use of the Eatwell10 plate. Some
were surprised at their lack of knowledge about where to place foods on the plate:
There were quite a few items that we put in the wrong section – I was quite
su p ised at that…. The othe thi g e got totall
o g as the o de i
which the number of calories in different foods. Not one of us got it right.
10
The Eatwell plate provides a consistent message and demonstrates how much of each food group
should be incorporated in to the diet, it is promoted by the Food Standards Agency
http://www.food.gov.uk/healthiereating/eatwellplate/
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Participants in another case study were also concerned about portion sizes given to children.
Some thought afterwards
hild is eati g… too
u h – forcing two Weetabix down them,
he o e ould e e ough . Other important messages related to specific foods and again,
participants were surprised at their previous lack of knowledge:
Hydrogenated fat has just scared the living daylights out of me and has
helped oth i the o kpla e a u se a d i
ho e life. I just a t
elie e ho
a thi gs ta geted at hild e that it s i , ho
a s eets…
and the salt content of things really surprised me as well.
We te ded to thi k e should gi e the
did t k o as u h as I thought.
4.5.2.2
half fat
ilk,
hi h
as
o g…I
Behavioral and attitudinal change
Respondents to dietitia s questionnaires were asked whether they intended to make
changes or had made changes to their eating behaviour as a result of the course; 85% (963)
intended to, or had already changed their eating patterns. Fifteen percent (175) however,
did not intend to change their diet, some already had healthy eating habits, others may have
not have been ready to change at that particular time.
Some viewed the course as
something to be applied in a vocational rather than personal setting; this was reported as
being particularly pertinent to the training specific to early ea s settings which targeted
infants and toddlers.
Overall, attitudinal and behavioural change could occur quite rapidly. However, where
courses were run over a number of weeks, changes in behaviour were observed before the
end of course, whereas for those run over 2 or 3 days, intention to change, rather than
actual behavioural change, was recorded.
As can be seen from Table 4.8, increased consumption of fruit and vegetables, fluids and
fibre were reported, as were decreases in fats, salt and sugar, snacks and fizzy drinks.
Healthier, more balanced diets were reported, with some respondents reducing snacks, or
starting to have breakfast. Comments from a range of participants illustrate the personal
impact of attending the OCN course:
We eat more fruit and vegetables, especially things like soups because you
a hu k thi gs i a d ou k o the e i the e ut the fa il do t so
the ll eat the .
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In addition, the courses had impacted, not on just the individual, but were also extending to
othe fa il
e
e s. The e
as e ide e, f o
oth i te ie
t a s ipts a d dietitia s
reflective comments, of participants making changes to their own diet and that of their
families and friends and of losing weight:
The last ou se… ith outh o ke s, a lot had hild e a d the said do ou
a t to see ho
u h ette
hild s diet is o . I o l gi e the
ilk a d
ate to d i k et ee
eals a d I do t let the ha e thi gs .
Moreover, there appeared to be a more thoughtful approach to food. Shopping habits had
changed and labels were being read, with a number indicating that their whole approach to
food had changed; meals were being planned and healthier cooking methods were being
adopted with less reliance on processed foods as the following quotes from case study
interviews illustrate:
Started to use a steamer because the veg taste different and crunchier.
Converted to organic meat and spend hours in the kitchen, cooking and
washing up. And if I eat junk I feel different (quite ill, quite ugh, unpleasant),
so it s had a assi e i pa t o
e. It s also heape .
E e though it as o l OCN Le el it as eall i depth. So i te esti g…
a d thi gs eall do sti k. … A d it s a azi g ho it affe ts ou he ou go
home. You think maybe I should use the o
ead ot the hite ead. …I
ha e sta ted shoppi g diffe e tl , eadi g the la els o e. Befo e if I d see
15 grams of suga I ould t ha e had a lue hethe that as high o lo . …
Thi gs like d i ki g ate a d ha i g a da . I also u h more aware of
how much salt I add in cooking and casseroles and soups, I add lentils and
throw a couple of peppers in to get the 5 a day.
I go for the cheap prices but for a couple of pence more you can buy
something much more healthy. The more expensive stuff that you think will
be healthier is not and often you can make your own much cheaper.
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Table 4.8 - Cha ges
ade to ou se pa ti ipa ts diet ( Rank order)
Changes made: reduce sugar and fat intake
Changes made: eat more fruit and vegetables
Balanced diet
Read labels
Cook more, use less processed foods
Salts
Plan meals
Increased fluid intake
Increased fibre
Healthier cooking methods
Portion sizes
Reduced portion sizes
Weaning
Changed family diets
Oral health
Increased fish intake
Exercise
Eat breakfast
Reduced snacking
Eat Breakfast
Increased calcium intake
Less fizzy drinks
Less coffee and tea with meals
Less carbohydrate
Less red meat
216
213
142
75
75
41
34
33
15
12
11
11
10
8
5
3
3
3
3
2
1
1
1
1
1
4.5.2.3. Increased confidence
A recurrent theme in the evaluation was confidence to deliver nutritional knowledge. All
respondents reported having increased confidence in disseminating information to clients
and gained reassurance from having OCN notes to refer to if necessary. Community Cafe
staff reported increased confidence in menu planning, whilst in nurseries, schools and other
early ea s settings staff had more confidence in advising parents, colleagues and others
Two case studies o
e ted o the i
eased o fide e i , a d ha ges i , s hool ooks
behaviour, such as encouraging children whilst serving them at the kiosk by telling them that
certain foods are healthy, and removing salt from tables. In area, the head of catering was
keen to make changes after attending the course and course participants would frequently
contact the dietitian to ask for advice:
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
I get a phone call asking for advice on nutrition in school. One rang to ask
ho
u h MSG should e allo ed i s hool g a . It s i e that the ould
give us a ring to ask if we had an opinion on it.
In another case study, school nurse health care support workers, who previously did
administrative tasks, were now attending the OCN course to enable them to provide one-toone advice. This
assi el i
lesso o thei o
a d the
eased thei
o ale a d o fide e…the go a d deliver a
e ha i g o e-to-o e ith kids .
Across a number of case studies school nurses, health visitors and food technology teachers
reported increased confidence in giving dietary advice. They used information from the OCN
course in their work with families and children and cascaded nutrition messages through
many different means:
In addition to giving the confidence to disseminate and use their nutrition knowledge, it
appeared that respondents were also more confident in their ability to learn, with the
manager of school cooks reporting that there was:
Increased confidence following attendance in uptake of offered education
sessions including mandatory and statutory sessio s a d further continuous
professional development activities e.g. attending other accredited courses
has been subsequently eagerly undertaken.
Furthermore, another reported that attending the course had helped them gain an NVQ in
childcare.
4.5.3 Impact at the community level
The impact of courses on the wider community can be seen in how course participants used
and cascaded the learning from the course (see Figure 4.2) and in responses to
questionnaires from community members.
It was reported in the interim report that, although participants planned to use the learning
in the work place, due to the recency of the training few course participants had had the
opportunity to use the nutrition information learnt, although this was intended. Plans in
2006-2007 were to cascade nutritional information and healthy eating messages, including
the development and delivery of nutrition packages, to specific groups.
Such groups
included breast feeding women, weaning groups, parents, school children, Cook and Eat,
colleagues etc. In addition, it was planned to disseminate the information across the
community, for example, by using the learning in the training of key workers, and offering
courses for school caterers and community workers. Others planned to change the foods on
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offer in schools, early ea s settings, and youth clubs, and to provide healthier options; for
example, to have healthier snacks on offer; encourage the consumption of fruit and
vegetables, and reduce the amount of salt and sugar in meals or plan healthier menus.
By 2007-2008, the findings reported in the Minimum Data Set revealed that much of what
had been intended was being delivered. Course participants in all areas reported having
used the information in the work place, covering schools, pre-schools, after-school clubs,
hospitals, hild e s ho es
and community settings, such as youth clubs, mentoring
schemes, food co-ops and other community based settings,
i fo
as well as passing this
atio o to olleagues. A o di g to dietitia s efle ti e o
e ts, the i pa t of
the scheme could also be seen in youth and leisure services, who demonstrated a greater
awareness of the value of nutrition in their role. Participants had changed their working
practices and were encouraging others to have healthy diets, through a range of activities
and also making changes to menus and foods offered. This was occurring on the ground but
also at a strategic level.
Delivery of
Food and
nutrition
education in
the schools
Share
knowledge with
staff and
colleagues
Delivery of
Food and
nutrition
education in
the community
Delivery of
Food and
nutrition
education in
early year’s
settings
How the
learning
has been
used
Training Key
workers
Menu planning
Adaptation of
recipes
Provision of
healthier
options
Figure 4.2 - How OCN course participants used course information
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Across all settings the portfolios built up through the course appear to have been put to
good use, with course participants reporting that they used information, activities, quizzes
and games in their own settings to cascade information and also to refer to when faced with
a query. A number had developed files, recipe booklets and other information which was
available to or distributed to their client group
Across the case study areas, work in schools, nurseries and youth and leisure settings were
some of the most important settings for changes in eating habits to be fostered.
Fundamental to the impact of projects on communities was the way in which information
was being cascaded to community groups. One case study contacted senior staff within
organisations, who then cascaded information to other areas:
We have a development officer, pre-s hool pla g oups asso iatio … the
so eo e else f o WCMA, ho also o e s othe a eas. So the e a le to go
to othe a eas a d sa this is ho it s o ki g he e a d the i flue e the
a it s set up i othe a eas.
The food co-ops were also important, as they were growing in number and more people
were using them, with healthy start vouchers often being used to purchase produce. One
case study promoted food co-ops by providing flyers advertising food co-ops in their
weaning packs and in Snack Award settings:
I had a all f o the de elop e t offi e to sa that the d hea d a out the
£2 bag of fruit and veg from the OCN course and people were ringing up and
asked he e the ould get it f o . So it s li ki g up ith othe i itiati es as
well.
The impact of the scheme could also be seen in youth and leisure services, who
demonstrated a greater awareness of the value of nutrition in their role. In one case study,
for example, youth workers had organised food co-ops and had placed healthy food recipes
in with the food:
The youth inclusion programme has started Get Cooking as a result of the
ou se, th ough the Co
u ities Fi st a ea…. o the e getti g the
o fide e to go a fe steps fu the , hethe that s a full lo
p oje t o
adding on extra bits to the food co-op.
The way in which messages were conveyed to people in the community was also important
for respondents and this meant being responsive to their needs. One respondent, for
example, taught a group of mothers who wanted to lose weight:
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
I gave the health eati g i fo atio … hat a po tio size is… a d ho
e
go o e the top….E e o e pa ti ipated … We did… the fo al stuff a d the
did sit there and listen and responded so I think if it was to go a stage further I
would do sessions on nutrition.
This respondent was concerned, however, that the public may have difficulty understanding
complex nutritional information and that a lot of people e e i te ested i p a ti al ad i e cooking demonstrations – so this is the e t step .
The projects were also impacting on communities by changing behaviours of key workers
and by conveying healthy eating messages which also impacted on communities. For nursery
staff, the CSIW had set e tai sta da ds a d had e o
labeling. A o di g to dietitia s efle ti e o
e ded a da s t ai i g o food
e ts:
The inspector for the CSIW reported the course has increased the confidence
of learners to pass on information about nutrition to parents and change the
food provision for children in their care.
The standards also supported the knowledge they had acquired. For example, they are
required to check ingredients and not to use hydrogenated fat:
The k o the ha e to use p odu ts that a e lo i sodiu a d e e gi e
them a list of the popular foods from which to hoose. The e ot allo ed to
use sausage rolls or Angel Delight (it has to be a proper fruit whip) and to
reduce processed food as much as possible.
As in the nurseries, the changes in schools and the wider community were evident within the
data. Some of this was evident in youth clubs, in which in one example, Community Food
Workers were planning to cook soup, jacket potatoes and wraps and salads and pizzas:
Even if they get the healthy options here and go home and tell their mum and
dad that the e had a g eat pizza that the e ade the sel es a d so a
they do it at home. They come in now on Thursday and say what are we doing
this eek, hat a e e aki g…. the e ot u i g a a f o
e o .
They ask if they can have a go.
In this same case study, women in a healthy eating group, some of whom had never cooked
before, were taught cooking skills, and went on to prepare something and bring it into the
sessio s. They enjoyed it and had their certificates, but went on to prepare the meals
the sel es .
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4.5.4 Impact on early years settings
Significant changes were apparent in early ea s setting with the information gained from
courses and the dietitians being used to overhaul menus, and develop a healthy eating ethos
within these settings influencing the behavior and attitudes of children, staff, and parents
(Box 4.1)
In nurseries, child minders, pre-school groups, mother and toddler groups or the home,
nutrition information was being used to inform parents about a range of topics such as
dental health, nutrition and weaning. One respondent wrote, We e o de ed WAG ea i g
magnets and given them out to pa e ts
ea i g thei
a ies . Child minders and nursery
staff were advising on the use of appropriate drinking cups and snacks for dental health.
Another respondent had Gi e out leaflets ad isi g healthie pa t food ideas, fi ge food
ideas a d healthie s a k ideas f o
t ai i g pa k to pa e ts . Others reported giving out
recipes and another reported that they had changed the p i ted fo
the ai
of g eate t a spa e
i i fo
at of thei
e us ith
i g pa e ts of ualit a d hoi es a aila le .
In addition to the provision of information to parents, the increased awareness of child
nutrition had resulted in these settings making changes and improving the quality of food
provided, or allowed. A typical nursery menu prior to the course would include unlimited
sandwiches, followed by crisps, cake and biscuits. Parents might bring in sweets, crisps, fizzy
drinks and cakes for their children for snacks during the day, or as a snack when picking
them up, and children would often go home and not eat their tea.
As i di ated i dietitia s efle ti e o
e ts, the e e e sig ifi a t ha ges to the
e us
in all nurseries concerned, including reduction in salt, sugar and trans fats. Changes such as
the removal of processed foods such as meat products from menus and the avoidance of
dried fruit as a snack were reported.
Everything is casseroles and roast dinners and pasta and everything is made
on the premises.
A nursery lunch consists of new potatoes, ham, cauliflower cheese, green
beans, roast dinner, cottage pie, pasta Bolognese with courgettes, peppers in
it. They have more than the five a day. We hardly give any milk, just in the
morning, then just water throughout the day.
As one dietitian observed:
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There was an improved balance of food provided in nurseries – limited
hydrogenated fats and salt, reading labels, less processed foods, increased
fruit and vegetables, less use of sugar.
Additionally there was evidence that the learning gained from the course was being used in
educational activities to teach pre-schoolers about food and linking with the foundation
stage curriculum. Young children were involved in activities such as growing and preparing
vegetables and others reported that they had ordered resources, such as posters and foods
model, for the children to play with.
Our pre-schoolers will eat anything, the younger group are choosy and we
have these fruit and veg activities that we had from the dietitians and we
do loaded it. We e used it … fo thi gs like ke a s a d the e see olde
hild e doi g stuff a d thought ou kids a do that…
One project reported that there was an enhanced awareness by nursery staff of the need to
model appropriate behaviours and also to encourage staff to eat healthily
They [staff and children] all sit around the table to eat and never do at home
a d e do t fuss the if the o t eat, ut gi e the a lap if the do eat.
If ou ake a fuss he the do t eat the thi k ah got a
u itio he e .
They often coax children to eat by putting food on their own plate and then
allowing children to taste it, thus introducing foods which previously they
would not eat.
In other nurseries staff had changed their own attitudes towards food, which was reflected
in how they encouraged children and advice they gave to parents:
Child e ill sa I do t like that a d e sa
do t fo e the . If it s ot a epta le afte
something else.
ut ou ha e t t ied it ut e
atte pts e ha ge it fo
M attitude has ha ged. I did t like eg a d so ould t push hild e if
the did t like it. No the do t ha e a hoi e e ause I do t allo
unhealthy food in the building.
I used to ad ise pa e ts ot to o if the do t a t thei tea, the
a huge s a k. No I thi k that s a ful.
e had
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Box 4.1 Impact in early ears’ setting
Changes in what is provided
Less salt and sugar
Buy Birds Eye fish fingers rather than cheap brand, no more chicken nuggets
Removed breadsticks and cream crackers due to salt content
Replaced milky puddings with yoghurt and fruit pudding
White bread replaced with brown
Raisins now given with meal rather than as snack whenever they wanted them
No biscuits or crisps unless for special party and even then very little
No sweets before 11 am and no sweet foods at breakfast break
Fruit juice at lunch time (because of corrosion of teeth), then water in morning and
afternoon
Children need some fat, so the right type of fat is used
Do not disguise vegetables and children do eat them
Cha ges i staff a d hild e s eha iou
Encourage children by all sitting together and eating without thinking about it
Children now sit and eat meal with parents
Give children very small amounts and then increase slowly as they get used to it
Children do not ask parents for sweets anymore – stickers used as rewards at the nursery
P o ide taste i to e ou age hild e to taste le o , the suga , the ho e
Reducing water used in cooking and reducing cooking time
Fewer complaints from staff (following attendance on course) about children not having
much of a snack
Staff replaced their McDonalds lunch with wholemeal sandwich
Staff keep up-to-date
eadi g a out food o the et a d i pape s
These attitude changes even occurred within a context of financial burden, as indicated by
one nursery owner, who spent about £500 a month more on food,
fo p i ate,
he it s ou
usi ess, ut if eeds e, the that s
hi h is a lot of
hat
e do . Changes in
attitude also occurred in parents and children. As one participant recalled, pa e ts
i loads of f uit a d
o e
ought
hole eal sa d i hes to the pre-school party. Befo e the d ha e
ought i loads of s eets, o
the e s o e . One of the most illuminative examples of
attitude change can be seen in reports of different children:
O e hild has s eets i he ag that ha e go e otte e ause she s lost
i te est. Whe she sees othe hild e eati g the she ll look a d the put
hers in her bag, but not eat them.
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We e ha i g a i thda party and one has brought in a cake, but the cake
ill e left e ause the e ot used to eati g it. A d so eti es the ha e
potato edges fo tea, ut the do t like the . The e lea i g hat to eat,
the ll sa I ll taste that a d that. The like oast dinner with cabbage and
parsnips.
4.5.5 Impact on schools
Within school settings, healthy eating was high on the agenda; catering trainers and
managers were delivering training and information to ensure that school catering staff were
aware of nutritional issues, su h as the ala ed diet. As epo ted i o e a ea, the
aki g su e all staff a e
were
iefed o health optio s a d a oidi g usi g salt i all ooki g . As
a result of such increased awareness healthier cooking methods were adopted in schools,
recipes were being adapted to incorporate more fruit, vegetables and fibre into dishes, and
effo ts
ee
ade to i
o e egeta les o
ease the a aila ilit of f uits a d egeta les to pupils
putting
e u.
Moreover, school caterers (in seven areas) were reported as being proactive in encouraging
children and young people to choose healthier options and were actively trying to educate
hild e
telli g the
a out foods , e ou agi g hild e
to eat
o e f uit and
organising tasting sessions for example. In one setting, caterers had taken this a step further
a d ha ged thei st le of deli e
to a self-service approach to encourage children to
appreciate the importance of making healthy choices for themselves. This has proved very
successful.
In addition to the changes in school catering practices as reported above, other professionals
such as school nurses, school nursing assistants, and community food workers, were
delivering sessions in schools on healthy eating. In some cases this was part of a health
promotion rolling programme which includes healthy eating sessions in primary schools .
Other examples included the development of food and nutrition workshops and the delivery
of OCNs in secondary schools, and after-school cooking clubs.
In additio
to the ha ges i
s hool ate i g p a ti es, dietitia s
efle ti e o
e ts
described the success of SNAGs in secondary schools, with commitment from pupils, staff
a d ate e s, through attending regular meetings and contributing to discussions and
a ti ities o
a s to i p o e s hool food .
One case study described how, at the behest of children, they replaced burgers as a snack
with whole meal toast
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Kids went wild about it and they had a choice of marmite on it and other
things, then we introduced jacket potatoes with a salad bar. The uptake was
phe o e al. The ooks said the ould t like it. The e t i ute the said it
as fa tasti a d the ooks do t feel th eate ed e ause e e al a s
involved them and asked how feasible things are.
Furthermore, a Nutrition Focused Peer Education Programme was also working particularly
well:
Young people are so enthusiastic and eager to learn. By investing time to help
increase their knowledge on food and nutrition we are beginning to see positive
cha ges i attitudes … e a e looki g at the positi e i pa t that pee s a ha e
encouraging others to choose healthier food and drink options.
Children were also being taught about food by course participants who showed them fresh
fruit and cut it up so that they could taste it. In one case study vegetables were grown in
recycling bins. Subsequently, parents developed their own allotments, having been
encouraged by what their children had done. Community Food Workers were also influential
in discussing necessary changes with head-teachers. In some schools, for example, attempts
were made to introduce fruit juices:
But if I go out to s hool I sa it s a e o
e datio i Appetite fo Life, so I
tend to have a chat with the head and the co-ordinator to try and get rid of
the f uit jui es, e ause the a t ha e f uit jui es i et ee
eal ti es –
at meal times is fine.
Children were also active themselves in finding out about and informing others about food,
via their involvement in SNAGs and many children joined the SNAG committee. In one
secondary school there was a waiting list of 15-20 to get on the committee and get involved
i
Get Cooki g . The
e e allo ed to u th ee g oups a d hild e had
eated thei o
rules for membership so that those who failed to attend three sessions were withdrawn so
that so eo e else ould joi . I this s hool, hild e had also requested to go into primary
s hools a d dis uss
hat the
e doi g . In another school the SNAG committee was
o e ed a out hild e s f uit a d egeta le intake:
Children were not eating many fruit and veg at lunchtime, so we came in and
did the activity and they were very interested and we put together a
questionnaire for the school of what fruit and veg everyone would like to try.
So last week we had salad tasters and the committee did evaluations and this
eek the ha e a salad a , so that s i pa ted the hole s hool.
4.5.6
Impact on catering for looked after children
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Withi
a ed fo
setti gs the e
as also e ide e of the k o ledge ei g used.
indi idual, o ki g o a hild e s a d
O e
ote:
I have put together a file containing the relevant nutritional information for
parents which they can access, as well as erecting a wall display containing
healthy eating messages. We have also worked with the hospital kitchen to
ensure that the way in which meals are cooked are healthy - they have now
changed from frying to baking, and the children on the ward have access to
fruit every day which is sent up from the kitchen.
Ca e s of looked afte
hild e
ere more aware of the need for good nutrition and were
passing this information on to the children. They were making changes to the food served
and bought, and as one respondent wrote:
We e defi itel
labeling session.
ha ged
hat s i
the up oa ds
o
si e doi g the
4.5.7 Impact on snack provision
Snacking is an issue which has been addressed in a range of settings and through initiatives
su h as the Gold S a k A a d S he e
ithi ea l
ea s setti gs de eloped
Cae phill
dietitians). Six dietetics projects reported that trainees had targeted this and were now
providing healthier snacks in a variety of locations including early years, schools, after-school
events and youth clubs. Moreover, they were actively educating children, workers in afterschool clubs, parents and carers (of looked after children) about healthy snack options. In
t o a eas ou se pa ti ipa ts had ad ised s hools o
health tu k shops
i di iduals assisti g i the setti g up of health tu k shops i
4.5.8 Impact on community members
The i pa t o the ide o
u it a also e see i
o
ith o e of these
s hools.
u it
e
e s espo ses to
questionnaires distributed by OCN course participants. Community members completed
questionnaires when they had received nutritional advice and information through an event
or activity they had attended. Questionnaire items were designed to elicit any impact that
this might have had on them personally. Further impact evidence was also gleaned from
comments made by OCN course participants and dietitia s o se atio s. Not all p oje t
dietitians had had the opportunity to follow up impacts in the community or to distribute
questionnaires. However, 141 questionnaires were handed out, and a 90% (127) response
rate was achieved. Most respondents were female (118, 93%) and classed themselves as
white (99%). Whilst ages ranged from 16 and under to up to 70, the greatest proportion
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
(74%) of respondents were between 26 and 49 years of age. Ninety-one percent were
working either full (66%) or part time (25%).
Similar to OCN course participants, the questionnaire responses indicated new learning and
almost all (99%) had learnt something new. Portion sizes, healthy eating for children, food
labeling, fruit and vegetables, increased knowledge about fats and sugar in food, healthy
eating, eating on a budget, weight management and foods for a healthy heart being the
most common examples cited. Course participants were asked whether, as a result of the
information provided, they may alter their diet. A high proportion responded positively to
this uestio a d i di ated that the i te ded to ha ge thei o
% a d thei fa ilies
(72%) diet. As can be seen from Figure 4.3, respondents intended to increase their
consumption of fruits, vegetables, fish and lean meat, and to eat fewer fatty and sugary
foods.
90
80
70
60
50
40
30
20
10
0
I intend to eat more of these
foods
I intend to eat less of these
foods
I do not intend to change
Figure 4.3 Dietary changes intended by community members (% response)
A smaller number of respondents completed follow up questionnaires (35), however all
reported that they had made changes to their diets. As detailed in Figure 4.4 there was
evidence of increased consumption of fruit and vegetables, fish, lean meats and starchy
foods and lower consumption of fatty, sugary and full fat dairy products. Community
members reported that they read food labels and made changes such as reducing salt,
caffeine consumption, and portions sizes as well as increasing fluid consumption.
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
120
100
80
60
40
I eat more of these foods
20
I eat less of these foods
0
no change in consumption
Figure 4.4 Dietary changes made by community members (% response)
Although not all OCN course participants or dietitians were able to assess the impact of their
input on community members, others noted a willingness to take up nutritional advice, a
greater interest in food, and trying new foods. Workers in a range of settings were seeing a
greater acceptance of the healthier foods and snacks being provided in community, youth
schools and early ea s settings, and adults, older children and young people were observed
making healthier choices. Greater thought was being observed around food as individuals
realised the impact it could have on their lives (as illustrated in Box 4.2).
Some groups however were more resistant to change. One youth worker specifically noted
so e esista e i the e ellious
-16 year age group, with boys being less willing to make
changes than girls. These comments however were few, and from the information provided
children were reported to be eating more fruit and vegetables as evidenced by comments
made by parents and those working with children and families.
In one area, feedback from young people in schools trained as peer leaders revealed how
they were using this information to influence others:
The e s
it too.
o e f uit i the house hi h e ou ages the est of the fa il to eat
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
I have put people off eating take-always now they know about all the bad
thi gs! I help people k o all this i fo atio …telli g people ho f uit a d
egeta les affe t ou dail outi e .
Box 4.2 Impact from the perspective of community members
I have changed from sweet cake bars to natural fruit bars and cereal. I feel better about what
I eat and have actually seen the results. I have less spots and feel less sluggish.
I e a e o e a a e of ….food s i pa t o health. It does ha e a i pa t o
e e ise.
E e Satu da I pla foot all a d o Su da ug a d afte I knackered but food does
ha e a i pa t o ou life. Si e eati g healthie I e had ette e du a e a d that s uite
i po ta t. It s uite pleasi g to k o that food does a tuall ha e a i pa t o ou life.
Basically, if you can eat healthy, I think you should. It does t just ha e a effect on playing
sport, it does have an impact on your life.
I lost a lot of weight through eating healthier and not snacking as much. I also ended up a lot
fitter than I was. I play rugby.
Stopped drinking pop just cut it out cos I think it was wrecking my teeth.
I o use food a d a ti it dia ies to look at people s i takes. Clie ts lea
ui kl ho to
identify problem areas One of my clients was delighted as she has reduced her mass by ¾ of a
stone in 6 week, her activity levels have i eased d a ati all .
E e o e is illi g to t ….I e do e ga li
ead f o s at h a d the the fa il
liked that a d it as so eas to ake ….I ought a a a a d sli ed it a d the all
de olished it. A d it as t eall ti e consuming. My children have much more
e e g o . It s ot the t pe of e e g that ou get f o a a of oke, he ou e
s api g the of the eili g. It s slo e ut the a keep o goi g – and he used to
s a k i et ee
eals o
isps ut si e I e ee gi i g hi the eals he does t
snack any more.
Some, especially younger children, seemed more adventurous and more confident about
food, and trying new foods and the efforts of the early ea s settings were appreciated by
parents. As one parent oted You got X to eat peppers!! And cherry tomatoes! Keep up the
good
o k! Moreover parents reported that children were actively requesting fruits as a
snack:
I have noticed that Y likes to eat apples a lot more, even requesting them as a
snack. She e e disliked the
efo e, ut she defi itel e jo s a
oe
types of fruit much more than she did before.
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
I have noticed Z start to ask for fruits, the things he never did before,
especially orange. Something very cool for me.
The learning and exposure to different foods was making it easier at home as children were
more accepting of the healthy options, as one parent wrote:
S does not eat anything extra as a result of the change, but we have found
that she accepts healthy snacks without a battle between meals. It makes
healthy eating at home easier for parents!
This was considered quite a breakthrough as it is often more difficult influencing parents
than children. In attempting to influence parents, one OCN participant, following completion
of the ou se, sta ted doi g health eati g fo
hild e s pa ties a d had sta ted ad e tisi g
this. One of the community members was also planning to set up a group and had become
an EXTEND leader for over 50s, whilst another planned to deliver Level 1 practical cooking
skills ith a o e s o kshop.
Moreover, parents appeared to be taking notice of the foods offered to their children and
were said to be attempting to make efforts in the home to provide healthier foods for their
children. There were also accounts of parents replicating the nursery diet, paying attention
to the provision of healthier weaning, finger foods, snacks and party foods. Young people
who had undertaken the OCN were reported to be influencing the diet at home. There was
evidence of a shift i pa e ts a d ou g people s k o ledge, attitudes a d eha iou s
towards food. As a result of the information, healthier packed lunches and snacks were
being provided for children in early years and school settings, and in a number of cases these
changes were dramatic. For example, one child minder reported:
One of my mums used to bring instant pasta in a sauce and super noodles
with crisps and a bag of sweets or chocolate (not given, child minder provided
own food instead). With this she used to bring a bottle of sugary drink. I gave
her a healthy snack leaflet and talked about what sort of food C should be
eating every day. I told her that I gave C red and white grapes and he loved
them. Over a period of a few weeks things started to greatly improve. This is a
sample of the food [mum] brings now (photograph of homemade chicken,
vegetables and potatoes) with fresh fruit and yoghurt as dessert.
A othe o se ed parents have stopped bringing in bottles of coke and tea and bring more
fruit since we sta ted the a a d . In some cases the provision of healthy foods in the day
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
care setting meant that parents perhaps felt less guilty of providing not so healthy options at
home, as one parent was cited:
[He] enjoys his snacks – especially fruit and crackers. I am glad [he] has a
healthy diet with you as it makes up for the hash browns and sausages he has
with me!!!
4.6 Evaluation of projects and successes and challenges
Dietitians had continued to evaluate their work using questionnaires developed for the
projects. They also relied on feedback from sessions delivered, distribution of questionnaires
1 and 2, monthly staff meetings, and use of questionnaires by nurseries.
4.6.1
Successes
The successful parts of the courses tended to relate to its flexibility, including providing
supportive information on websites for those who wanted to know more (Box 4.3). Being
responsive to questions was considered very important, even if it meant finding out and
feedi g a k late . As o e dietitia
o
e ted, they ask some complex questions, one was
asking about the vitamin C content of orange juice and how long it takes to biodegrade once
ope ed .
Some specific parts of the course regarded as successful included food labeling, visual
examples, and quizzes, and weight management:
The like ui k ullet does utte o tai
o e fat tha
a ga i e ? A d
the ll sa of ou se it does, a d I ll sa , o it s diffe e t fats . A d the
follo i g eek the ll tell e that the told the sa e to othe people at work.
For one case study, the food labeling session resulted in people cooking from scratch rather
than buying processed food, and the life stage nutrition approach enabled them to apply the
knowledge to themselves and their families.
Guest speakers being used for some sessions, including the Rural Regeneration Unit, an
agrifood specialist and leisure services. A number of dietitians had also completed a Post
Graduate Certificate in Education, and their experiences teaching OCN courses had enabled
them to improve their lesson planning and project management skills and to consolidate
their teaching experience.
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Box 4.3 Successes from perspective of dietitians and course participants
Successful parts of the OCN course
Flexibility and responsiveness
Food labeling – resulted in people cooking from scratch
Eatwell plate, quizzes and weight management
Application of information to the participants themselves
Weight loss
Personal development of dietitians
Successes post-course
Following participants up in Get Cooking
Work with school catering
Nutrition Focused Peer Education Programme
SNAGs in secondary schools – commitment from pupils, staff and caterers
Impetus for SNAGs in primary schools following school governor training
School logo prize for healthy eating helped change culture in a school
Successes reported by course participants
Healthy foods and cooking methods used by school cooks.
Children requesting healthy options
th
OCN L2 delivered to 6 form students, who have used the opportunities of SNAG and OCN
th
in the selection of 6 form prefects.
A COMMUNITY FOOD WORKER grew vegetables with parents, who now also grow things at
home.
Play group staff grew vegetables in tyres and parents are becoming interested.
Food co-op established in an area where there was no outlet for fresh produce.
I ol e e t i SNAGs de elops hild e s so ial skills. The o
u i ate ith go e o s
when they visit.
Support from dietitians
Other successes related to following course participants up in the community, such as with
Get Cooki g a d
ok
ith s hools. I o e case study, a SNAG set up following a training
session with school governors, resulted in nutrition policies being made in both primary and
secondary schools. In this case study, healthy eating had worked particularly well in a school
because it was part of an after-school club and an entity in itself:
We had a competition for a logo and motto which we ran throughout the
school and we had a local surf shop donate a prize, so it was high profile and
it as o all the s hool add ess s ste s…, a d as e tio ed at the new
parents evening.
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Many successes were also reported by the course participants themselves. In schools, cooks
were using more fruit and vegetables and not overcooking them, reducing salt and not
purchasing bicarbonate of soda. In fact once particpants explained the reasons to school
ooks, the
e
o e u de sta di g a d the the t
a d get a it of f uit i the spo ge .
Relationships with dietitians were important in supporting these changes in school cooks as
they provided guidelines on types of food, and checked nutritional content of menus.
Child e s i ol e e t i SNAGs
as a
ajo su ess a d hild e i
join. Examples of their work included a p ese tatio o
the ea
easi gl
a ted to
hat the do as a SNAG g oup to
s , and organisation of an induction into the canteen:
Ofte the a i e a d it s uite o e hel i g a d the just u
hat the
pe so i f o t of the has ought. It s just the e u a d the p i es, so that
parents can see how much money they need to purchase a good meal.
In this school SNAGs had enhanced the relationship with school cooks because children,
rather than adults, had requested healthy options. Catering staff then reported to SNAG
meetings indicating the high demand for healthy options and reduced sales of unhealthy
foods from vending machines. Cooks were also considering obtaining certain ingredients in
the kitchen before taster session were organised. Plans were made to offer children merits
for choosing healthy options, which would contribute to points towards school trips. As one
participant reported, children attended school council meetings where nutrition was
explained and they could see for themselves the sugar content of cereal bars. As a result
they stopped selling cereal bars in the tuck shop.
One of the important successes for course participants was the support they gained from
dietitians for them to develop their role. Dietitians were readily available to provide advice,
such as on menu changes or special diets, and were happy to deliver sessions in the
community. Resources provided by dietitians such as food models were welcomed by
participants, as were the CD, DVD and the Cymru Cooks Kit:
The esou es I e had ade a aila le to e f o dietitia s has ee
fa tasti . The e all o the e d of the pho e a d the provided the food
models for me to use with the kids.
Course participants also found the course file useful and were using it in their teaching, for
example, to compare food labels:
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The file is supe , so eti es I go a k to it o …, e ause I do asse lies
a d so eti es the ha e do e ut itio a tio a d I use a lot of hat I e
learnt on that course.
Teachers had also found dietitians supportive in helping them to fight for extra time for
personal and social education. Such comments testify to the importa e of the dietitia s
role in providing continuing support to course participants in the community.
At a more strategic level, course participants appreciated the support from the Welsh
Assembly Government. This included the translation of the government website into Welsh
which teachers referred to in their teaching, as well as various policies, such as the Food and
Fitness policy, and Appetite for Life, which underpinned health initiatives.
Much of the success of the initiatives, however, relied on those involved cascading
information, and participants described successful strategies they used to pass information
on, as a result of their attendance on the OCN course (Box 4.4).
Box 4.4 Strategies introduced to pass information on
Training of nursery staff by nursery manager
Displays of nursery menus for parents
Educating parents of nursery children
Use information from file and food mats and models in teaching
Taster sessions advertised and reported on at school assemblies
Breakdown on Eatwell plate on school planner
SNAGs produced a leaflet for the years 6s to take home
Young people representing Food Matters have been in primary schools doing healthy
eating - made fruit kebabs for charity and sold them
Healthy schools section on school website which SNAG contributes to
PSE lessons and peer mentoring
Attend school council meeting and talk to children about basic nutrition and ask what
they are selling at their fruit shop (e.g. cereal bars), then compare sugar content of
different cereal bars.
Strategies to pass information on began as early as nursery, in which children were involved
in making pizzas, pitta bread and flap jacks as part of their experiential learning. Nursery
managers and cooks also conveyed information to nursery staff and parents and nursery
staff, in turn, informed parents about updated menus. One nursery, displayed daily menus
for parents to see:
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The k o
e e t i g to do ou est fo the hild e …, e ause the e
i flue ed fo he the get olde …telli g the
hat e e gi i g them –
the f uit, a d e t a d tell the a out the salts a d the suga s .
O e u se
a age had se u ed fi e pla es fo the e t OCN ou se. I did t k o
aisi s e e ad fo the . I a t
staff edu ated i that a . The e s o l
that
-2 now who I
a t ait to get o the ou se . Equally, information was conveyed to a nursery manager by
a participant of the OCN course, as her manager was doing NVQ Level 4 and wanted to know
what she had learned on the course.
In schools, the OCN course had also been an important source of information for
participants and was impacting on how nutritional information was conveyed to children.
Some participants used the OCN resources, as part of healthy schools days and festivals:
The children from primary schools come up to the high school and they do a
couple of food activities and physical activities using the food mat and
models.
S hool u ses also o t i uted to these i itiati es, a d had pushed so much and given so
u h i fo
atio to the hild e
des i ed ho
that they now needed to work with parents as well. They
hild e app oa hed the
a d say I had this in my packed lunch today, or
he I e t ho e este da I had this .
Another success reported by a COMMUNITY FOOD WORKER was a healthy eating club,
which, although focusing on weight loss, involved healthy eating rather than fad diets and
required one member to bring in a different recipe each week. The COMMUNITY FOOD
WORKER i ol ed
as hopi g that the g oup
ould e o e sta d alo e afte the p oje t
finished as numbers had increased over the past 7-
o ths a d the had completely
ha ged thei eati g ha its .
4.6.2 Challenges
Despite the success of the course, a number of challenges were also reported, most of which
related to capacity issues (Box 4.5). The OCN course was demanding in terms of
commitment, both for course participants and deliverers. For course participants, 10
sessions was quite a commitment if they had to take time from work. There was also a lot of
i fo
atio to a so
he ha douts of additio al optio al sessio s
e e provided and
discussed because they were relevant to all participants.
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Box 4.5 Challenges reported by dietitians and course participants
OCN course delivery
OCN course demanding in time for both deliverers and participants
Pressure to deliver OCN courses within a tight timeframe
Prioritising between course delivery and following up course participants in the community
Lack of Level 1 and Level 3 OCN courses
Workload involved in moderation and slow return of portfolios when moderated externally
Monitoring of those who had completed Level 2, whether they need a refresher course or
on-line forum
Early years
Resistance from nursery staff due to personal preferences and budgetary constraints
Lack of contact with parents by nursery staff
Weaning children off processed foods due to inclusion of addictive additives
Influencing parents, as many do not know how to cook
The need providing healthy food within budgetary constraints
Schools
Resistance from school staff due to excessive workload or lack of support from senior
management
Unsuitable catering and canteen facilities in schools
Lack of teachers trained in home economics
School staff are poor role modules due to unhealthy eating habits
Diverse role for school nurses limits the amount of time they can spend on nutrition
education.
Resources
Lack of resource capacity to provide sufficient support to food workers
Lack of support to help professionals working with families to set up healthy eating clubs
Access to fresh food and culture of fast food industry
For dietitians, there was pressure to achieve results in a short time frame to correspond with
the end of the Project funding period11. Core funding of dietitians to deliver OCN courses
was therefore suggested:
11
Projects were initially funded until March 2009, however the Welsh Assembly Government have
since extended funding until 2011
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Without Dietetic Grant Scheme funding it will prove difficult to maintain
continued delivery [of OCN courses] as it will place pressure on other
Community Dietitians, who are not employed by the Dietetic Grant Scheme,
to carry on this good work. This raises the issue of whether there is an
opportunity for Dietetic Grant Scheme dietitians to become core-funded.
Pressure to achieve results also caused difficulty when prioritising between delivering OCN
courses, following up those who had completed courses, and managing other aspects of
projects. In one case study, 70 people had completed the course and needed to be followed
up, ut the e t g oup
as a p io it , so
e eed a tea
fu di g eeds to go i to it so e a see health p o otio
Once the ou ses
as it s getti g igge so
e o i g
oe
o e i teg ated .
e e o pleted, the dietitia s ole the i ol ed suppo ti g those
ho
had completed the course so that they could set up their own projects including delivery of
OCN courses. One dietitian was planning a networking day for those who had done OCN
ou ses to e su e the , ha e t i te p eted a thi g i o e tl a d also offe suppo t a d
supe isio . Another dietitian had visited all the after-school clubs:
You just see all these kids a d the e eate foods the e e e see efo e
and one little gi l told e she d e e t ied a potato; she d o l eate i sta t
potato at home.
For other dietitians, staffing issues caused difficulties with capacity. In one case, two food
workers had started and left within the two year period:
Funds need to be available to recruit a food worker to establish and support
the practical cookery clubs, and to support the work that has grown over the
2 years. Currently, supply within the dietetic services is being outweighed by
the demands in the catchment area.
One project had been u a le to offe the Le el si e the
the depa tu e of the Co
iddle of Septe
e
due to
u it Dietitia . These changes caused a number of disruptions. In
one case, for example, the food worker was expected to collect and collate information
pertaining to measuring the impact of the project in the wider community. This is because
the e is u e tl a lack of support to help health visitors, and other professionals who come
into contact with young people and young families, to set up thei lu s .
For other dietitians funding was needed for facilities, such as venues and ingredients for
ooke
lu s a d fa ilities to e a le people to deli e Cook a d Eat sessio s, as people
want the practical work to complement the theory of the OCN .
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Moderation and certification also presented difficulties. Significant delays in the
development and moderation of courses resulted in some projects renegotiating contracts
with other providers. Moderation was also demanding for some dietitians due to the high
workload involved and it was hoped that they would soon become an accredited centre so
they could moderate themselves. To ensure quality and a consistent approach, in some
areas projects became involved with OCN Wales and developed local OCN working groups to
share good practice.
The main problem, however, across all case studies was the availability of Level 1 and Level 3
Co
u it Food a d Nut itio
training. Suitable organisations and individuals had been
identified to deliver Level 1 OCN courses direct to the community, which will enable further
cascading of information and development of skills whilst giving the opportunity to gain a
qualification. However, at the time of reporting, no courses had been run. Similarly, the
Level 3 course developed which would support others to deliver Level 1 OCN and increase
the availability of training was due to be piloted. It must be noted, however, that teaching
Level 1 OCN is not dependent on the acquisition of Level 3 if staff are already skilled (e.g.
youth worker). Delays in the roll out of these initiatives were perceived to have hindered the
plans of projects and partnerships, and this has put a strain on dietetic resources.
Another difficulty faced by projects was resistance, mainly from nurseries and schools.
Dietitians deemed it important therefore that someone from each setting attended the
course:
Staff ill sa
he e s the s uash go e …. The ll sa it s a it ea ot to
gi e isps a d ho olate. We e had eal su ess ith the staff ho e come
o the t ai i g a d o u de sta d h it s i po ta t fo hild e s teeth
et . T aditio al s a ks of ho olate a d isps ha e all go e o a d e e
suggested alternatives they can give.
Course participants confirmed that some nursery staff failed to encourage children to eat
thi gs like atu al ogu t e ause of thei o
as a e a d the
ill t
dislike fo it; yet if you offer a child a sticker
a thi g . In one nursery, the dietitian was called in to persuade
them to remove Angel Delight:
The dietitian came to discuss it with us and my employer and I was told that
u less e ga e up A gel Delight I ould t a o
ith the ou se, e ause
of the hydrogenated fat in it.
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In some nurseries, cooks were particularly resistant and PARTICPANTSs worked hard to
influence them, which was proving successful:
Waste was a problem at first from a business point of view. But I explained
that hild e had to get used to it. Whe ou e stu k i ou a s a d a e
used to gi i g hild e hat the like, it s ha d o k and it can be a bit more
expensive sometimes.
Resistance of parents of nursery children was also a concern to course participants and it
was thought that busy parents will find it hard to give fresh foods to children because it is
difficult to wean them off processed foods due to their addictive additives. Participants from
nurseries recounted how parents regularly bring in crisps and strong juice for children even
though it is ot allo ed a d ofte sho little i te est i thei hild e s ut itio :
I said she d had a i e eal toda , a d he
we e got a M Do alds i the a .
othe said oh it does t
atte
They o e i a a o the us a d go ho e at p o the us a d it s a jo
to e e get asi i fo atio o e to the a out thei hild s da . I e tried
ith pa e ts afte oo s a d thi gs, ut the just do t take off.
Pa e ts sa the e glad it s Mo da e ause at least the ll eat fo ou; all
e e had at ho e is M Do alds a d pizza. The do t eat at ho e . The
mothers often say, what do you feed them in nursery and we say have a look
i the ook a d the sa the a t elie e the eat that.
Some nursery staff too were limited by cost and could only be convinced to introduce
something new and unusual if there was no waste; they were working to a tight budget as
businesses and staffing is expensive, so ou do ha e to e se si le a out it... I use f oze
eg. It s a
atte of keepi g the ost do
hilst also ei g health .
Parental attitudes were also problematic in school children, and there had been a complaint
in one school about a burger van selling directly to children, although it was believed that
this had now been stopped. As discussed by community members (cooking club parents), it
can be hard when shopping on a budget because a bar of chocolate is only 30p. Added to
this was the problem of encouragement by fast food outlets to purchase unhealthy food
options:
When you go to McDonalds and buy a happy meal for £1.99 and you want
water with it, they charge you 98p on top. But if you want a carton of milk
with it or a Fruit Shoot ith it, it s fi e, o a ilk shake o a oke, ut fo
water they charge extra, which is wrong.
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The culture of fast food in fact was thought to be compounded by poor access to fresh
produce due to lack of money or transport to obtain fresh food, as well as a poor knowledge
base. The combination of these factors resulted in people buying what was advertised in the
media and displayed on supermarket shelves:
Local prices are higher than in town, so people will find it easier to go to the
fish and chip shop than to go and spend £4-5 on fruit/veg for the week,
because some food would be wasted, particularly if working late and coming
i at p
he it s too late to eat….So lifest les a e a othe a ie .
Overall, course participants believed primary schools were more successful in conveying
healthy eating messages than secondary schools. Some participants believed this was due to
the lack of choice given to primary school children over what they ate, only healthy food
being available.
Dietitians and course participants alike also reported problems in schools, often due to
tea he s e essi e o kloads a d la k of suppo t f o
se io
a age e t. Child e a e o
longer taught home economics; teachers are no longer trained in food and nutrition and
recruitment of suitably qualified teachers is difficult:
There are qualifications around to train teachers which are starting now with
the curriculum change..., but unless you have someone from county education
for your faculty telling your senior management team what they should be
doi g it o t happe .
In one school, whilst the head teacher was on sick leave the deputy head teacher reintroduced corn snacks and biscuits because she thought children were hungry . The
dietitian therefore offered a free place on the OCN course to the Learning Support
Assistants, which resulted in new supplier for the tuck shop with all fruit-based snacks.
Course participants also provided examples of teachers being poor role models, with salt
always being present on the staff table:
The head teacher comes and collects two plates of chips and takes them back
to he offi e a d that s hat the hild e see. The sa e s hool e su es that
drinking water is available for children all the time, but wo t let the ha e
cups.
They had a healthy eating week and children still observed teachers eating
biscuits with their tea. They will say they need a treat. They should have
enough intelligence. Whenever I go into a school the biscuit tin disappears.
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One participant believed such difficulties arose through lack of direction from education
policy and that a link with the Local Education Authority was vital. In this particular case, the
OCN course had been vital:
The OCN course has given food the best status in our school this year, but if
I
ot a le to get that suppo t f o edu atio it s goi g to e diffi ult. … I e
given my own time after-school ut a t o ti ue this. The ll sa the
ha e t got the staff a d the
o t get a
e ause the e a e t any out
there trained in food.
In another school, the senior management team had not formally approved healthy eating
changes and wanted to integrate the SNAG into the school council. This had been
unsuccessful due to competing issues on the school council agenda:
Big organisational challenges need to be addressed before the SNAG stands a
chance - for example catering and canteen facilities - the way the tills are set
up eates a ottle e k so the a t get the hild e th ough i ti e; the e s
no stagge ed lu hti es so the e t i g to se e
pupils i o e hou .
Other challenges in schools included practical and financial considerations, such as physical
restrictions, demands of profit targets, and resources for Welsh translation. In one school,
physical restrictions occurred at the point to sale, where all the food in one place caused
congestion. Another school relied on vending because of the size of the canteen, whilst in a
third the kitchen was not based on the premises. Financial targets also limited creativity of
cooks:
The ha e a out
se o ds to se e ea h pupil, so hild e do t ha e a
ha e to see hat s a aila le – the e ushed th ough, a d if ou go i to
the a tee ou see the pe so i ha ge ou ti g o e . …she s fed up… she
wants to cook. One of the dinner ladies did do the OCN course and she
benefited a lot from it.
For school nurses, an additional limitation arose from their statutory responsibilities relating
to smoking, sexual health, screening, and child protection. As most school nurses were
responsible for between four and seven schools, group work would be necessary to deliver
healthy food messages to parents. They considered that one session with a year group was
insufficient as continuity is needed, which requires additional school nurses. If
s hool u se fo e e
e had o e
s hool the i pa t ould e sig ifi a t .
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4.7 Long term sustainability
Sustainability in the long term is important to the future development of dietetics projects
and this requires the consideration of long-term funding of Community Dietitia s a d
community food workers, and provision of adequate training and physical resources to
support these roles (Box 4.6).
4.7.1 Meeting the needs of nutrition education in nurseries and schools
A key role of many course participants was education of children in nurseries and schools
and they emphasized the importance of educating children from an early age so that they
will demand freshly cooked food at home and try different foods when they start school.
One participa t des i ed ho a pa e t asked he for the recipe for my fish pie because her
hild e
eall like it . Nursery staff had therefore confiscated unhealthy snacks brought in by
pa e ts, as it as e essa
to keep hippi g a a at it :
You ll get the
i gi g a ottle of Coke fo the hild… We lea e it i the
hild s o a d let the take it a k ho e agai .
In schools, children were already influencing what food was supplied and SNAGs had created
the opportunity for them to try different foods and to be given a voice through surveys
indicating their preferences. Some children, for example, had expressed a preference for
tuna and sweetcorn baguettes rather than chocolate . It as the efo e o side ed esse tial
for catering staff in both nurseries and schools to attend OCN training to respond the
changing preferences of children and to ensure consistency of healthy food messages. One
nursery participant stated that this should be a Care Standards Inspectorate Wales
requirement. Having sent 5 staff on the course, this participant had made many changes:
To ha e o ta t ith the dietitia s is g eat… We e o ki g ith de tists o
a d e e ha ged the eake s o e to f ee-flo ups a d e e told pa e ts
about this as well.
4.7.2 Resource implications
OCN courses, however, have long-term physical and human resource implications in a
number of respects. Most dietitians had resolved printing and administration problems
identified in phase 1, although two were still doing their own photocopying, teaching
preparation, a d p epa i g files, as ell as deli e i g t ai i g a d atte di g
eeti gs. It s a
assi e thi g to do fo o e pe so . Overall, the consistent message was that centrally
produced resources are needed to support projects as these would free up time for
dietitians to support the
o fide e to ook p og a
as ade of lea i g f o
those t ai ed a d e a le deli e
of
e.
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Box 4.6 Key messages for sustainability
Educate children from early age (confiscate unhealthy snacks brought into nurseries by
parents)
Attendance of nursery staff on OCN course (make OCN course a CSIW requirement)
Attendance of catering staff on OCN course
Embed healthy eating into the curriculum
Remove unhealthy foods from vending machines in schools
Ensure children are given a voice through SNAGs
Improve links between nurseries and schools in relation to nutrition
More longer term funding needed to support some ongoing projects
Influence people at a strategic level
Partnership work to ensure consistency of nutrition messages from people in different
fields (e.g. health and education) and to integrate initiatives.
Rolling out of nutrition messages through community groups.
Ensure adequate resources to support OCN provision (food models, centrally produced
resources, allocated budget for production of resources).
Physical resource implications also arose for course participants once they had completed
the OCN course as they had been introduced to initiatives that would later require
resources. However, dietitians have limited resources to offer the amount of support
required:
You sho people so ethi g o the OCN a d the sa , that s a g eat idea, ut
the the ha e t a tuall got a o of esou es…. I had so e eall good
youth workers who are just chomping at the bit to get out there and a CD to
the is t u h good he the ha e t got a p i te a d also ha e fu di g
issues.
Whilst dietitians were innovative in sharing existing resources for course delivery (such as
food models and flip charts) the food models varied so much that they did not match the
ga es. A sta da d set of food
edu ed ate,
odels
ould the efo e e useful that we could buy at a
hi h all s hools a d u se ies a d s hool u ses ould ha e so that the
e
usi g the sa e thi g . One suggestion proposed was for resources to be the same for all
OCN courses, with standard variations according to age groups,
e ause the e s diffe e es
in sizes of pieces of bread and fruit and what a portion is – so just trying to keep that
edu atio
o siste t .
Human resource issues
i po ta t
e e also aised
o side atio s fo lo g te
oth dietitia s a d ou se pa ti ipa ts a d a e
sustai a ilit . Dietitia s
ie s ega di g the
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operation of their support role and the need to monitor and update course participants, was
consistently found throughout the data. Indeed, reflective comments highlighted the need
to support and monitor OCN participants to e su e that the utilise thei
thei e e da
date
e k o ledge i
oles and to provide ongoing refresher courses and training to e sure up-to-
o siste t
essages
o ti ue to
e sp ead . However, some dietitians needed
additional resources to help them to support other professionals in delivering healthy
ut itio
essages. The appoi t e t of dieteti s assista ts
as see as a positive move
and whilst one case study respondent was still awaiting such an appointment, two expressed
satisfaction that a dietetic assistant was now in post to assist the dietitian and provide Level
1 skills courses to the wider community:
Inclusion within the team of a project support officer has been very useful in
terms of meeting the project aims and objectives. The skill mix encourages a
responsive team able to drive forward training at multiple levels.
Similar lack of human resource capacity beset course participants, some in schools being
u a le to deli e
oth ut itio a d ooke
to deli e othe thi gs as
skills i the ti e allo ated e ause the
have
ell . School nurse participants explained that their role is wide
ranging and includes nutrition education in addition to sexual health, child protection and
first aid. In one case study, hand washing has been requested in primary schools from
reception through to year 6, and this was considered unrealistic. Working with one primary
school (rather than 7) was suggested as the way forward to meet the requirements of
schools:
I o p ehe si e s hools ou a t deli e
si gle ea g oup, a d e e if ou …said
eati g, ou d the go from having seven
p i a ies to o e a d if a s hool u se
goi g to get fed up ith fi st aid … e ill
e e si gle thi g i depth to e e
t o s hool u ses just do health
primaries to cover to having 30 +
as ased i a s hool ou e just
e s allo ed up fi st aid.
Some argued that the only way to meet the need for nutritional education was for a
directive from government to ensure the embedding of healthy eating within the
curriculum:
I s hools, it s dou tful if the ll do it u less it s pa t of the u i ulu … if
the e aged -14 they should have some sort of cooking.
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Integrating nutrition into a new course on healthy life was proposed as one solution,
particularly as a lot of children do not attend Guides and Brownies (where nutrition is
commonly taught).
Su h
Go e
ajo
ha ges i poli
e t, ou t
ould e ui e joined up thinking between Welsh Assembly
ate i g, s hool staff, hild e a d the ate i g staff . Links between
nurseries and schools could be one way of transferring healthy food messages from nursery
to school, as in one case, in which the nursery manager had told the local head teacher
about the initiative and the head teacher had agreed to co-operate.
4.7.3 Long term roles
Future sustainability also relies on the long term roles of the participants, which some
suggested should be strategic in nature; and one participant was planning to use her role
ith the Food a d Health St ateg to get people f o
highe up i the ou il i ol ed :
We need to build up relationships with people first in order to change their
minds with evidence, so they can see children using this experience in order to
get somewhere in life... the e is o k that is t e essa il ei g sha ed
across the city, so projects in some schools need to be presented at one of the
head tea he s o fe e es.
Working strategically also involves partnership, which some participants believed could be
used to improve the consistency of messages from people in different fields, such as health
and education. Partnership work could also be translated to integrating existing initiatives,
including food workshops (developed through Lottery funding) Cymru Cooks, OCN Food and
Nutrition, Clued up on Food (for primary school age group) and Eating Healthily 1-2-3
(recipes and healthy food messages for teenagers).
Working with community groups was also cited as a way of rolling out healthy food
messages and some of those involved had completed OCN training. Some community groups
suggested included: food co-ops, cooking clubs, cooking with parents, allotment groups, and
cooking with Brownies, Scouts and Guides. Produce from the cooking clubs could then either
be consumed on site or at home and produce from gardening sessions could be used in
after-schools clubs:
I am confident that with the food co-op, café and healthy eating club, healthy
options with children at the è he, the e s e ough the e to oll out.
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Students want to know about nutritional content of food and want labels on
food they can purchase on campus. Healthy outlets are becoming attractive
to teenagers.
School nurse and community based participants also stressed the need to provide sessions
on healthy eating on a budget for parents:
Wo k togethe
ith fa ilies, hild e a d pa e ts… ooki g o kshops.
Engaging the parents, the kids would love it and peer pressure would bring
othe s alo g too…. I ha e pa e ts ho a t ead a d ite a d I d lo e to do
cooking groups with them – picture menus and engage parents.
Community Food Workers were perhaps the group with the widest remit of future roles in
nutrition (Box 4.7). One, for example, was liaising with the dietitian and setting up an expert
panel:
We will be picking up things from the OCN course, so that we can make sure
that all staff ha e the app op iate OCN t ai i g. We ll also e looki g at ho
we can link in with Cymru Cooks work as well and producing our own
materials.
Box 4.7 Examples of future roles of Community Food Workers
Recruit cooks to Cymru Cooks
Food co-ops, plus target those who do not know how to cook the vegetables with cookery
classes
I stigate a o
u it allot e t g oup… put togethe a lo al fa e s o allot e t a ket
to supply the food co-op and café with home grown produce- Plant it, Grow it, Eat it
Mentoring scheme in the community to mentor volunteers to enable them to work with
young people in relation to healthy eating
Cooking classes after-school
Deliver Level 1 OCN and cooking skills to parents
Wo k a ou d health f ie ds – a buddying model – 10-11 year olds are teaching 7-8 yr
olds in after-school clubs
Training to volunteers to develop their skills in nutrition and the values of it
Work with college/university students to teach them about different food groups and
cooking skills
Lack of long term funding, however, was already limiting the amount of support that
participants could provide within their community settings. One illustrated this with the
termination of the subsidy to a local café when the funding period came to an end. They had
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been subsidising the café for 2 years, offering a free food initiative – a piece of fruit with
each meal, or free range eggs. According to this participant, as a consequence of the
withdrawal of funding, some initiatives ceased due to the cost:
It is important for people to become independent and to roll initiatives
fo a d the sel es, o e the had ee set up….The allot e t ill ha e a
effect on the whole village by providing food for the co-op and café and
fa e s a ket.
5
Discussion of key findings
This section of the report reflects on the key findings from the evaluation. The findings
reflect the views of dietetics professionals and those who attended the courses
provided by dietetics professionals with a view to enhancing their knowledge of
nutrition so that they could cascade this information within the communities in which
they worked and members of the communities in which they work.
5.1
Delivery of initiatives and courses
A vast number of courses and events were delivered - 220 by September 2008 –most
being over-subscribed. During 2007/8 at least 5,000 individuals attended courses and
events delivered by dietitians. OCN courses in particular generated over a thousand
enrollments of which 97% completed successfully. Course participants included health
and community professionals, volunteer groups and community members, thus
increasing the food and nutrition knowledge amongst community workers. This was an
important outcome as it was specified as a medium-term goal of the grant scheme
(WAG, 2006; Appendix 1). This multi-disciplinary mix created networking opportunities,
which enabled participants to access different facilities. Participants valued the
recognition of the OCN qualification, which for some enhanced their future job
prospects.
Courses were delivered fle i l to a o
odate pa ti ipa ts
o k, edu atio al a d
personal commitments, and this was appreciated by trainees. Course participants also
valued the demonstrations and course materials (e.g. package, websites), which
promoted their skills to enable them to cascade information using similar teaching
methods. Collection of data on key messages learnt from the course revealed that
participants now felt equipped with appropriate knowledge, confidence and techniques
to deliver healthy food messages within their own settings.
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5.2 Partnership work
One of the short-term goals of the grant scheme (WAG, 2006; Appendix 1) was for
dietitians to develop links with other programmes and partnerships and by September
2008, 184 separate partnerships were recorded. Most were local and included NHS,
public health, and Local Authority departments. Some partnerships were within
dietitia s o
se i e a d e a led the
to sha e good p a ti e. Nearly half of the
recorded local partnerships were strategic in nature, concerned with development of
local strategy, policy and standards. Others were concerned with developing initiatives,
providing training, or promoting the food and nutrition project, and providing a forum to
facilitate information exchange. Whilst it must be acknowledged that many of these
partnerships were not developed by the programmes themselves, dietitians were
proactive in accessing and influencing these partnerships, as well as encouraging the
development of other types of partnership, such as SNAGs.
Partnership work enabled dietitians to become involved in many different initiatives run
by other projects/organisations, often in an advisory capacity where initiatives required
nutritional input. Involvement with such initiatives provided dietitians with
opportunities to promote OCN and other courses, thus enhancing recruitment.
5.3
Supporting and developing other initiatives
Dietitians developed, delivered and managed initiatives, such as non-accredited training,
roll-out of the Gold Standard Snack Award Scheme (developed in Camarthen) in
childcare settings, a peer-led nutrition project in schools and School Nutrition Action
Groups. They also advised on the development of other initiatives and resources, as well
as on impact assessment, and implementation of local policy. Dietitians thus became an
important resource of specialist knowledge, both strategically, and practically when
advising on content of menus and cookery packages. They also participated in
community and work-based events, such as in schools and colleges, and were involved in
SNAGs, Snack Award Schemes and Cymru Cooks.
5.4
Impact of programmes
The programmes had an impact at different levels – the organisational (strategic) level,
the individual course participant level and the wider community level.
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5.5
Organisational (strategic) impact
At the organisational level, partnership working was beneficial to long-term sustainability
and this was consistent from all the data sets and interviews. Much of the organisational
impact resulted from partnership working, with alliances increasing throughout the
duration of programmes. Nutritional expertise of programme dietitians was drawn upon
widely across partnerships at a strategic level, and dietitians were enabled to access
target groups within their organisations and networks. Through their association with
different initiatives dietitians strengthened their networks, which improved partnership
work. This in turn led to sharing of information, opportunities to cascade training and
nutritional information, and for programmes to inform strategy and policy. Crucially,
the e as e ide e of dietitia s
o k ei g e
edded i to the st ategi pla s i
a ious
health and social care settings and there is potential for this to continue further.
5.6
Impact on course participants
Responses to questionnaires distributed by dietitians revealed that 94 percent of course
participants had acquired new learning from the course and 85 percent intended to or
had already changed their behaviour. Changes made included more balanced diets with
fewer snacks, more fruit and vegetables, fluids and fibre, and less fat, salt and sugar,
snacks and fizzy drinks. They had also learned many new recipes and how to adapt them.
There was therefore an increase in the number of community workers delivering food
and nutrition training to 0-25 year olds, as required by the grant scheme (WAG 2006;
Appendix 1). They used information from the OCN course to encourage others to have
healthy diets through a range of activities and also making changes to menus and foods
offered. In this way they transformed dietary provision in schools, pre-schools, afterschool lu s, hospitals, hild e s ho es a d o
u it setti gs dis ussed fu the
below). Youth and leisure services also became more aware of the value of nutrition in
their role, with youth workers organising food co-ops and working with Communities
First on Get Cooking initiatives. In this respect the scheme has been successful in
meeting the requirements of the five-year Food and Fitness implementation plan (WAG,
2006), which emphasises the need for changes in schools, including healthy eating
vending machines and innovative ways of teaching nutrition/cookery skills to children
and parents.
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5.7
Community impact
At the community level, partnerships enabled programmes to respond to local need and
to improve access to quality, targeted, nutritional training and education in
communities. Partnership working also resulted in enhanced nutritional awareness and
improved cookery skills in communities, schools and colleges as well as a greater range
of nutritional resources being available for community events. All this impacted on the
eating behaviours of families through cascading of information.
Course participants influenced the communities they worked with, such as pre-school
providers, schools, hospitals and the community. They also disseminated information to
older people participating in a walking scheme and through their work with community
groups, such as Co
u ities Fi st a d a ou g people s foot all lu . Ha i g atte ded
the OCN course and been involved in Snack Award schemes, child minders and play
workers changed the eating habits of young children and gave advice to parents. Many
participants delivered healthy eating messages in schools using experiments and games.
Others impacted on schools through their work in school catering. Course participants
also influenced the eating habits of relatives and young people. As in similar
programmes reported in the literature (Kennedy et al ., 1998) such an approach reached
a much larger number of the public than the dietetics service would have been able to
do alone, and the feedback from those affected testified to its effectiveness.
The impact on the community was illustrated in various changes, including provision of
hild e s s a ks a d d i ks, ooki g egi es a d e ipes to fa ilitate health eati g.
Teachers were including nutrition in schemes of work and children were becoming
increasingly involved in SNAGs and were taking responsibility for influencing school
menus. Whilst it is not possible at this early stage to assess the impact on cost to the
health service - specified as a long term goal of the scheme (WAG 2006; Appendix 1) –
there is every possibility that changes taking place at the various levels of food provision,
together with changes in eating behaviour of children and young people, if maintained
will ultimately reduce the burden of nutrition related illness in the long term.
5.8
Successes and challenges
Many successes as well as challenges were reported from the programmes. The most
salient success was the OCN course, due to its cost effectiveness, its flexibility, its
contribution to the knowledge and confidence of course participants and the
effectiveness of the course resources. Good progress was made in reaching target
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groups, with changes in eating behaviour already evident in course participants and
information being passed on to the communities with whom they work. This had already
resulted in changes in food provision and pre-school, school and after-school settings,
with resultant changes in eating behavior. The medium-term goal of the grant scheme
relating to increasing the number of 0-25 year olds receiving information on healthy
eating was therefore achieved, as was the long term goal of changing the dietary
behaviour of 0-25 year olds ( Appendix 1).
As course participants were often indigenous to, or had professional roles within the
communities they served, they were familiar with the local culture and the
organisational elements of their community, which, as reported in the literature would
have enabled them to reach and mobilise members of the community (Brownstein et al.,
1992; Earp et al ., 1997; Eng & Young, 1992). Dietitians were proactive in sharing
resources with course participants, enabling them to disseminate information further.
There was increasing emphasis on work in community settings and the success of
SNAGs, Get Cooking and some similar initiatives. Innovative ways of growing vegetables
were also reported.
The main challenges to arise seem to relate to resources, which affected a wide range of
staff from different disciplines. Dietitians experienced the challenges of meeting the
increasing demands for OCN course delivery, whilst also providing the much needed
support for course participants in their community settings. The workload involved in
moderation of courses was also demanding and moderation was often slow. Dietitians
also reported frustration at the lack of Level 1 and Level 3 12OCN courses, which delayed
future progress. Whilst it was unrealistic for Level 3 provision to be available, the
vociferous nature of their views on this subject testifies to their enthusiasm in seeking
opportunities to further advance the education of course participants, with a view to
future sustainability of programmes.
12
Level 3 OCN provision was not part of the Dietetics Capacity Grant Scheme and had been instigated
later as a pilot. It was not possible therefore to implement this as quickly as dietitians would have
liked.
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Resource challenges also arose in community settings. Course participants, who were
often community workers, had to meet the demands of their existing role, which
sometimes did not allow for the inclusion of delivery of nutritional information to their
client groups. The need for delivery of nutritional education in schools, for example, is
high and yet the various professionals who work with school children already have
demanding roles. There is often too little time within the school curriculum for
nutritional education to be taught and children are no longer taught home economics –
indeed few teachers are trained to teach food and nutrition anyway. School nurses are
often considered to be ideally placed to fill this much needed gap. However, they were
unable to deliver the level of nutritional information required within their existing wideranging health promotion role. Although school mealtimes would be an ideal time to
i flue e hild e s food preferences, school cooks often did not have time to speak to
children.
The cost of the course and of purchasing equipment was also an issue for NHS Trust
staff. Budgetary constraints within nurseries and schools often resulted in resistance on
the part of staff to make necessary changes in menus.
Delivery of Level 1 and Level 3 OCN was an issue of contention as it was reported
consistently that both Level 1 and Level 3 courses were desperately needed but were
under development and not available at the time of reporting. The Level 1 OCN course is
a food a d ut itio skills fo
o
u it
o ke s. The Le el
OCN ou se is a t ai i g
the t ai e s ou se, hi h, at the ti e of epo ti g as still ei g piloted as it as ot
officially part of the Dietetics Capacity Grant Scheme. Whilst professionals with
appropriate community education experience can deliver Level 1 without completing
Level 3, those without such experience are required to complete the Level 3 OCN course
before they can teach Level 1. The current lack of availability of a Level 3 course for this
group was a source of frustration for some of these participants.
Although dietitians are still required to deliver some components of the Level 1
Community Food and Nutrition course, the availability of this course was deemed to be
esse tial to f ee up dietitia s ti e to e a le them to develop future initiatives, to
provide support to past participants, and other local developments. This imperative to
devolve responsibility for some of the dietitians
oles to app op iatel
t ai ed
community staff, is consistent with other research, and has been shown to be very
effective when trying to engage communities and partners in activities, so that dietitians
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can focus on managerial and strategic responsibilities (Lowe & Barg, 1998; Kim et al.,
2004).
Having completed the course, the main challenges faced by course participants included
the cost and marketing of processed food, which promoted a culture of not cooking
using fresh foods, and of not introducing healthy foods to children at an early age. This
challenge combined with the difficulties in influencing parenting skills and lifestyle
factors, as some people do not have the facilities or the wherewithal to have a healthy
diet (Anderson et al ., 1996; McGlone et al ., 1999). Expectations were also prevalent,
such as obesity being a barrier to attending a gym and age being an excuse not to eat
healthily. As reported elsewhere (Kennedy et al ., 1998; Kennedy et al ., 1999), provision
of cookery classes was becoming increasingly effective in addressing these issues.
6
Conclusion and recommendations
The evaluation of the Dietetics Capacity Grant Scheme has drawn on a wide range of
data from dietetic professionals, food workers, course participants, and statutory and
voluntary groups. The findings reveal how the scheme has been very effective in
improving the nutritional health of communities, which has been achieved through
partnership activities and cascading of information learned from OCN courses and other
events. There is evidence of dramatic changes in eating habits of course participants and
their families and in the culture of food provision in nurseries, schools and after school
provision.
Dietitians and course participants alike had many plans for the future to ensure
sustai a ilit i the lo g te
. As
ight e e pe ted, dietitia s pla s i ol ed tea hi g
Level 3 OCN and supporting and monitoring course participants once they had
completed the course. They also intended to strengthen existing partnerships and to
work with various initiatives, including SNAGs and the Snack Award Scheme, Flying Start,
allotments and Fun with Food. Course participants were also developing new roles as
they developed confidence. Their future plans included development of food co-ops,
contribution to food growing initiatives, delivery of Level 1 OCN, mentorship roles and
training of volunteers.
A strategic approach was suggested to ensure future sustainability of public health
nutrition services. Primarily, adequate resources were considered necessary, in the form
of longer term funding to support some ongoing programmes in order to enable them to
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develop into core services. In particular, the need for a permanent dietitian role as part
of public health team was emphasized. Part of the role of this dietitian could be to bring
partners together and facilitate other projects to take on food and nutrition. This in turn
would ensure integration of food and nutrition across different services, thereby
facilitating a change of culture around food. As an ongoing process, dietitians would also
need time to organise annual network events to update community food staff on
changes to nutrition policy and to promote further development and monitoring of
programmes.
Resources were an important issue to arise throughout the project. The main human
resource problem arose from a lack of dietetics capacity to respond to the high demand
for provision of OCN courses and to support course participants in their professional
roles once they had completed the course. The Community Food Worker role is crucial
for future sustainability of initiatives and their role could include delivery of OCN Level 1
courses, provision of cooking skills classes, and work with community initiatives, such as
allotments and food co-ops. However, there would still need to be sufficient Community
Dietitians to run OCN Level 2 and 3 courses and to supervise support workers. The
provision of OCN Level 1 and Level 3 courses was considered to be one of the most
important considerations to be addressed as the programmes moved forward. For
programmes to be sustained in the future, the findings suggest that course participants
who have completed Level 2 OCN courses (and who do not possess the appropriate
professional experience) should be able to progress to Level 3 and then to teach Level 1.
This
ould f ee up dietitia s ti e to tea h Le el
ou ses a d suppo t a d
o ito
staff in the community.
Strategically, it was also proposed to increase partnership work to ensure consistency of
nutrition messages from people in different fields and to integrate initiatives. This would
include closer links between health and education, and between nurseries and schools in
relation to nutrition. Such partnership work and integration, would, in the long term,
ensure the rolling out of nutrition messages through community groups.
At a more local level, changing the culture around food requires changes within early
years and school settings. To this end there was a consistency across the various data
sets that children need to be educated from an early age, and that unhealthy snacks
need to be removed from all nurseries and schools, including vending machines. It was
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also considered essential to embed healthy eating into the curriculum, and part of this
process would include involving more children in SNAGs.
Delivery of OCN courses was also seen as key to future sustainability, and for long term
success, a network of trainers is needed to deliver training as people leave. Selection of
appropriate course participants is also crucial and should include all nursery staff and
school catering staff. Furthermore, having completed the course, OCN participants
require long term monitoring and support to ensure consistency of nutritional messages
in the future.
Recommendations for future sustainability
6.1
From the evaluation and reflective comments of participants interviewed a number of
recommendations can be put forward to ensure sustainability of the programmes and
continued impact long term. These are as follows:
6.1.1
Strategic
Recognise and utilise the public health role of dietetics on a permanent basis.
Develop a network of trainers to deliver training.
Consider making the OCN in food and nutrition a required qualification,
particularly i ea l
ea s settings and schools.
Consider appointing more school nurses - if one school nurse was attached to
each school this would make a considerable impact.
Ensure nutritional education is included in the school curriculum.
Provide training for teachers in food and nutrition.
Provide long term monitoring and support to ensure consistency of nutritional
messages in the future.
6.1.2
Early Years, schools and community settings
Develop the role of Community Food Workers further to include delivery of OCN
Level 1 courses, provision of cooking skills classes, and work with community
initiatives, such as allotments and food co-ops.
Educate children from an early age, and ensure an environment that promotes
uptake of healthy food and drinks.
Embed healthy eating into the curriculum, and include children in this process
through involvement in SNAGs.
Recruit support workers as core staff as an ongoing process and with
appropriate supervision.
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Provide ongoing support to community staff on changes to nutrition policy and
promote further development and monitoring of such work.
Integrate food and nutrition across different services, thereby facilitating a
change of culture around food.
Continue development of OCN courses through Levels 1 to 3 to enable cascading
of delivery through the community.
Increase partnership to ensure consistency of nutrition messages from people in
different fields and to integrate initiatives. This would include closer links
between health and education, and between nurseries and schools in relation to
nutrition.
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References
Anderson, A., (2007) Nutrition Interventions in Women in Low Income Groups in the UK
Proceedings of the Nutrition Society (2007), 66, 25–32
Anderson, A., Ellaway, A., MacIntyre, S., McColl, K., Callander, R., & Oswald, J., (1996)
Community Food Initiatives in Scotland: Final Report. Edinburgh: Health Education Board for
Scotland.
BDA (2005): Personal communication: Miss Anne Pridgeon, representing the Community
Nutrition Group (CNG) to produce the BDA Guidance Document on the Roles, Responsibilities
and Development of the Dietetic Support Worker.
Bernstein, E., Wallerstein, N., Braithwaite, R., Gutierrez, L., Labonte, R., & Zimmerman, A.,
(1994) Empowerment forum: A dialogue between guest editorial board members. Health
Education Quarterly, 21 (3): 281-294.
Bracht, N., Tsouros, A. (1990) Principles and strategies of effective community participation.
Health Promotion International, 5 (3):199-208.
Brownson, C. A., Dean, C., Dabney, S. & Brownson, R. C. (1998) Cardiovascular risk reduction
in rural minority communities: the Bootheel Heart Health Project. Journal of Health
Education, 29 (3):158-165.
Caraher, M ., & Cowburn, G .,(2004) A survey of food projects in the English NHS Regions.
Health education Journal, Vol 63, (3): 197-219
Carleton, R. A., Lasater, T. M., Assaf, A. R., Feldman, H. A.,& McKinlay, S., Pawtucket Heart
Health Program Writing Group (1995) The Pawtucket Heart Health Program: Community
changes in cardiovascular risk factors and projected disease risk. American Journal of Public
Health, 85 (6): 777-785.
COMMIT Research Group (1996) Community intervention trial for smoking cessation
(COMMIT): Summary of design and intervention. Journal of the National Cancer Institute, 83
(22): 1620-1629.
Department of the Environment, Food and Rural Affairs (DEFRA) (2001) National Food
Survey 2000. The Stationary Office. London
Dennison, B., Rockwell, H. and Baker, S. (1998) Fruit and Vegetable Intake in Young Children.
Journal of the American College of Nutrition, 17 (4): 371-378.
Department of Health (1996) Low income, food, nutrition and health: strategies for
improvement. A report by the Low Income Project Team for the Nutrition Task Force., London,
HMSO.
Department of Health (2003a) Tackling Health Inequalities. A programme for Action. London
Department of Health.
Department of Health (2003b) Health Survey for England, HM Government
Department of Health (2008 ) Ambitions for health: a strategic framework for maximising the
potential of social marketing and health-related behavior. London
72
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Department of Health (2004) Choosing Health Choosing a better diet –consultation
document. London
Department of Health (2007) Healthy Weight, Healthy Lives A Cross Government Strategy for
England, London
Dowler, E., (2000) The Role of Community Food Initiatives. in McCormick, J. (ed) Healthy
Food Poli : o S otla d s e u?, Edi u gh: S ottish Cou il Fou datio , pp -29.
Dowler E, & Caraher, M., (2003) Local Food Projects: the new philanthropy? Political
Quarterley, 74 (1):57-65
Dowler, E., & Calvert C. (1995) Nutrition and diet in lone parent families in London. Family
Policy Study Centre. London
Earp, J.A., Viadro ,C., Vincus ,A., et al (1997) Lay health advisors: a strategy for getting the
word out about breast cancer. Health Ed Behaviour 24(4):432-451.
El Ansari, W. (1998). Partnerships and new ways of learning: a second opinion. National
Health Service Magazine, 15, Winter, 21.
Eng, E., & Young, R .,(1992) Lay health advisors as community change agents, Community
Health, 15 (1) 24-40.
Farquhar, J. W., Fortmann, S. P., Flora, J. A., Barr Taylor, C., Haskell, W. L., Williams, P. T.,
Maccoby, N. & Woods, P. D. (1990) Effects of community-wide education on cardiovascular
disease risk factors: The Stanford Five-City Project. JAMA, 264 (3), 359-365.
Food Standards Agency Wales and Welsh Assembly Government (2003) Food and Well Being
Reducing inequalities through a nutrition strategy for Wales
http://www.food.gov.uk/multimedia/pdfs/foodandwellbeing.pdf
Food Standards Agency (2002). National Diet and Nutrition Survey adults aged 16-64.
Volume 1
Goodman, R. M., Wheeler, F. C., & Lee, P. R. (1995) Evaluation of the Heart to Heart Project:
Lessons from a community-based chronic disease prevention project. American Journal of
Health Promotion, 9 (6): 443-455.
http://new.wales.gov.uk/topics/statistics/publications/health-survey200506/?lang=en
Gillies, P., (1998) Effectiveness of alliances and partnerships for health promotion. Health
Promotion International, 13 99-120.
Israel, B., Checkoway, B., Schulz, A.,& Zimmerman, M. (1994) Health education and
community empowerment: Conceptualizing and measuring perceptions of individual,
organizational and community control. Health Education Quarterly 21 (2):149.
Kelder, S., Perry, C., Klepp, K.,& Lytle, L. (1994) Longitudinal tracking of adolescent smoking,
physical activity and food choice behaviours. American Journal of Public Health, 84 (7):
1121-1126.
Kennedy, L.A .,& Ling, M., (1996 Nut itio edu atio fo lo -income groups - is there a
ole? In: Food poverty in welfare societies a reader. Edition Sigma, Berlin
73
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Kennedy, L.A., (2001) Community Involvement at what cost? – local appraisal of a panEuropean nutrition promotion Programme in low income neighborhoods Health Promotion
International, Vol. 16,1, pp 35-45.
Kennedy, L.A., Hunt, C., & Hodgson, P., (1998) Nutrition education program based on EFNEP
for low income women in the United Kingdom. Journal of Nutrition Education 30; 89-99.
Kennedy, L.A., Milton, B., & Bundred, P., (2008) Lay Food & Health Worker (LFHW)
Involvement in Community Nutrition and Dietetics in England: definitions from the field.
Journal of Human Nutrition and Dietetics, 21, pp. 196–209
Kennedy, L.A.,& Milton, B., (2008) Lay Food & Health Worker (LFHW) Involvement in
Community Nutrition and Dietetics in England: Roles, responsibilities and relationship with
professionals Journal of Human Nutrition and Dietetics 21, pp. 210–224
Kennedy, L.A., Ubido, J., Elhassan, S,, Price, A., & Sephton, J.,(1999) Dietetic helpers in the
community: the Bolton Community Nutrition Assistants project. Journal of Human Nutrition
& Dietetics. 12, 501-512.
Kim, S., Koniak-Griffin, D., Flaskerud, J.H., et al ., (2004) The impact of lay health advisors in
cardiovascular health promotion: using a community-based participatory approach. Journal
of Cardiovascular Nursing. 19 (3):192-9.
Labonte, R., (1994) Health Promotion and Empowerment: reflections on professional
practice. Health Education Quarterly, 21 (2): 253-268.
Labonte, R. ,(1998) A Community Development Approach to Health Promotion: A Background
paper on Practice Tensions, Strategic Models and Accountability Requirements for Health
Authority Work on the Broad Determinants of Health. Edinburgh. Health Education Board of
Scotland and Research Unit in Health, Behaviour and Change, University of Edinburgh.
Laverack, G., (2001) An identification and interpretation of the organizational aspects of
community empowerment. Community Development Journal 36:134-145
Laverack, G., & Wallerstein, N .,(2001) Measuring community empowerment: a fresh look at
organizational domains. Health Promotion International, 16 ( 2) 179-185
Lowe, J.I, Barg, F.K,& Stephens, K.. (1998) Community residents as lay health educators in a
neighborhood cancer prevention program. Journal of Community Practice. 5 (4):39-52.
Luepker, R. V., Murray, D. M., Jacobs, D. R., Mittlemark, M. B., Bracht, N., Carlaw, R., Elmer,
P., Finnegan, J.,& Folsom, A. R. et al. (1994) Community education for cardiovascular disease
prevention: risk factor changes in the Minnesota Heart Health Program. American Journal of
Public Health, 84 (9): 1383-1393.
McGlone, P., Dobson, B., Dowler E., & Nelson, M. (1999) Food Projects and how they work.
Joseph Rowntree Foundation, York, UK.
Moynihan, P., and Hyland, R., (2004) Design and evaluation of peer-led community based
food clubs: a means to improve the diets of older people from socially deprived backgrounds.
In: Peer-led Approach to Dietary Change. Report from Food Standards Agency Seminar.
Thurs Jan 22nd 2004: London. www.food.gov.uk pp 5- 9
74
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Neumark-Sztainer, D., Hannan, P. J., Story, M., Croll, J., & Perry, C. (2003) Family meal
patterns: Associations with sociodemographic characteristics and improved dietary intake
among adolescents. Journal of American Dietetic Association, 103 (3): 317-22.
National Food Alliance (1997). Myths about food and low income. London: National Food
Alliance, 1997
O Loughli , J. L., Pa adis, G., G a -Donald, K., & Renauld, L. (1999) The impact of a
community-based heart disease prevention program in a low-income, inner-city
neighbourhood. American Journal of Public Health, 89 (12): 1819-1826.
O Neill, M., Rebane, D., & Lester, C., (2004) Barriers to healthier eating in a disadvantaged
community. Health Education Journal, 63 (3): 220-228.
ONS (Office for National Statistics) 2001. Key Health Statistics in General Practice 1994-98.
Accessed from www.statistics.org.uk
Patton, M.Q. (1986) Utilization-focused evaluation, 2nd edition, Newbury Park, CA: Sage
Press ,V .,and Mwatsama, M., (2004) Nutrition + food poverty. A toolkit for those involved in
developing or implementing a local nutrition and food poverty strategy. National Heart
Forum; the Faculty of Public Health; the Public Health Group, Government Office for the
North West; the Public Health Unit, Government Office for the West Midlands; and the West
Midlands Public Health Observatory
Puska, P., Koskela, K., Pakarinen, H., Puumalainen, P., Soininen, V., Tuomilehto, J. ,(1976) The
North Karelia Project: a programme for community control of cardiovascular diseases.
Scandinavian Journal Social Medicine, 3 (4): 57-50.
Ritchie, D., Parry, O., Gnich, W.,& Platt, S., (2004) Issues of participation, ownership and
empowerment in a community development programme: tackling smoking in a low-income
area in Scotland. Health Promotion International, 19 (1): 51-59.
Robertson, A.,& Minkler, M. (1994) New Health Promotion Movement. Health Education
Quarterly, 21 (3): 295-312
Robinson, K. L., &Elliott, S.J., (2000) The practice of community development approaches in
heart health promotion. Health Education Research Theory and Practice, 15 (2): 219-231.
Roe,, L., Hunt, P., Bradshaw, H., & Rayner, M., (1997). Health promotion interventions to
promote healthy eating in the general population. - Health Education Authority, London
Rossouw, J. E., Jooste, P. L., Chalton, D. O., Jordaan, E. R., Langenhoven, M, L., Jordan, P. C.
J., Steyn, M., Swanepoel, A. S., & Rossouw, L. J., (1993) Community-based intervention: The
Coronary Risk Factor Study (CORIS). International Epidemiological Association, 22 (3): 428438.
SACN: Scientific Advisory Committee on Nutrition (2003) Salt and Health, London; The
Stationary office.
75
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Singer, M., Moore, L., Garah, E., & Ellison, R., (1995) The tracking of nutrient intake in young
hild e : the F a i gha Child e s Stud . American Journal of Public Health, 85 (12):
1673-1677.
Tudor-Smith, C., Nutbeam, D., Moore, L., & Catford, J. ,(1998) Effects of the Heartbeat
Wales programme over five years on behavioural risks for cardiovascular disease: quasiexperimental comparison of results from Wales and a matched reference area. British
Medical Journal, 316, 818-822.
Vaandrager, H.W, Koelen, M.A., Ashton, J.R.,& Colomèr, C. ,(1993) A four-step health
promotion approach for changing dietary patterns in Europe. European Journal of Public
Health, 3, 193-198.
Vaandrager, H.W. ,(1995) Constructing a healthy balance: Action and research ingredients to
facilitate the process of health promotion. Department of Communication Studies,
Wageningen Agricultural University, Netherlands.
Welsh Assembly Government (2007) Welsh Health Survey 05-06, Welsh Assembly
Government, Cardiff.
WHO (2003) Diet, Nutrition and the Prevention of Chronic Diseases, WHO Technical Report
Series 916, Report of a joint WHO/FAO Expert Consultation. World Health Organisation,
Geneva
World Health Organisation (1986) Health & Welfare Canada. Canadian Public Health
Association. Ottawa Charter of health promotion. Copenhagen: WHO 1986.
76
Appendix 1: FlowChart
Short Term
Each Trust
increases number
of community
dieticians and or
assistants
Grant
Scheme
established
7.
Intermediate
Long-term
Improvement in
Food and Nutrition
knowledge
amongst
community
workers
Increase in
number of
community
workers receiving
food and nutrition
training
Increase in
number of
community
workers delivering
food and nutrition
training to 0 -25
year olds
Increase in the
number of food
and community
Workers with food
and nutrition
qualifications
Increase in
number of 0-25
year olds
receiving
information on
health eating
Links to other
programmes/local
partners
developed
Increase in
number of 0-25
year olds with
food and nutrition
qualification
Changes in
dietary behaviour
of 0-25 year olds
Reduction in costs
to health service
of nutrition related
illness
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Appendix 2 - Minimum data set proforma
Diet and Nutrition Grant Scheme. Evaluation Template: Reporting period 3: 1st July 2008 – 30th
September 2008. Reports due 1st November 2008 (electronic submission is requested)
This document provides guidance and a template to enable you to produce a summary of your projects progress. The information you give will
feed in to the overall evaluation we are undertaking for the Welsh Assembly Government, and also will be useful for your own reports.
The content of the template is based upon the information you gave us at the Networking event and is split into three sections which relate to
the overall aims of the scheme.
Section 1: Delivery and organisation,
Section 2: Impact and perceptions of training
Section 3: Impact on the community.
This is a summary of evaluation you have collected therefore we do not expect reports to overly detailed, the form may seem long, however it in
landscape view and contains a number of tables into which information are to be inserted.
At the networking event you requested common questionnaires which could be used to support your evaluations, these comprise training
evaluation questionnaire (1) and follow up questionnaire (2). A further two questionnaire were developed to gather feedback from community
members (questionnaires 3&4).
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Section 1: Delivery and organisation
Project title:
When did your project start?
Delivery of training
Description of training delivered in reporting period 3 (1st July 2008 – 30th September 2008). Please provide details below, using a separate row
for each separate piece of training and any follow-up sessions you might have held
Title
and
short
description
Duration
of
training
course
Frequency of
sessions
(e.g.
once
per
week,
one-off etc)
Length
of
sessions
Is
the
training
Accredited?
Training
model
used e.g.
Level
1,
2, 3
Target
group
(e.g.
Food
Workers,
community
workers,
health
professionals etc)
Which
groups
attended
this
training?
Number
of men &
women?
M
Number
who
started
the
training
course
Number
who
completed
course
F
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Delivery of training
In addition to actual delivery of OCN accredited courses, the project dietitian provides support and one-to-one tutorials for those that require
additional help.
The project have also developed a database of learners to keep track of all learners that come through the scheme to assist with evaluation,
follow up and ongoing support.
Recruitment issues
What, if any difficulties have you had in recruiting course participants?
What action have you taken to address these difficulties?
.
If course delegates have dropped out, what are the main reasons which have been given?
.
What other initiatives have you been involved with?
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In this section we are interested in other initiatives (such as Breast feeding, Inequalities in Health projects, attending a health fair etc) that you
may have been be involved in reporting period 3 (1st July to 30th September) and the impact (if any) this has on your own project, these might
be positive or negative. Please do not include partnerships in this section (Please provide brief details below, using a separate row for each)
Name
individual/initiative/
organisation
of Description of the initiative
What impact has this on your What impact
project?
community?
has
this
on
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Working in Partnership with other organisations/initiatives
We are interested the partnership you may have formed (or are developing) during reporting period 3 (1 st July 2008 – 30th September 2008).
Partnerships could be with individuals, other initiatives, organisations as well as with other departments within your own organisation the impact
this has had on your project. Impacts, if any, might be positive or negative.
Name
individual/initiative/
organisation
of What is the nature of partnership?
What impact has this on your project?
What impact has this on the
community?
Please add more rows as required
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Section 2: Impact and perceptions of training
We have developed two questionnaires for participants of training, which you can use. These are: the course evaluation questionnaire
(questionnaire 1) and course follow up questionnaire (questionnaire 2).
You might want to collect information from every participant or decide to take a sample. However we don’t want to be too prescriptive here as
you will know what is feasible in terms of your own project. For example, it might not be practical to follow up delegates who have had a half
day of training, but if you plan follow-up training or networking events these would be an ideal opportunity for you to collect data.
We do not want to see the completed questionnaires. Rather, we would like you to provide us with a summary of the information you collect,
using the matrix below. Should you need any help and advice, about setting up a data base, analysis etc please contact us.
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Total number of questionnaires distributed Number of Course evaluation questionnaires Number of Course evaluation questionnaires
and returned up to 30th June 2008
distributed__)___
returned__ ____
Number
of
distributed__
Follow
up
questionnaires Number of Follow up questionnaires returned
Number of participants who believed that
they had learnt something about food and
nutrition that they had not known before?
What were the 3 most frequently reported
things that people rated as being the most
important thing learnt from the course?
Identify main themes and summarise by
using the number of occurrences e.g. effect
of too much salt n=67
Following training did participants intend to Number
change their own diet?
Yes __
This information would be available from
No____
questionnaire 1
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Nature of changes made by participants of
training
Identify main themes and summarise by
using the number of occurrences e.g. effect
of too much salt n=67
Which groups have participants of training
disseminated this knowledge to?
This information can be obtained from the
follow up questionnaire and diaries
How have participants of training used the
knowledge learnt from the course in their
work?
This information can be obtained from the
follow up questionnaire and diaries
Observed impact of
community members
the
training
on
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This information can be obtained from the
follow up questionnaire and diaries
Overall, how
training?
did
participants
rate
the Number
Very Good __ ___
This
information
questionnaire 1
is
available
from
Good _______)_________
Poor ________________
Very poor ____________
Can’t say _____________
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What improvements if any were suggested?
(info obtained from questionnaires no.1 and
follow-up interviews)
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Section 3: Impact on the community
This is probably the most difficult aspect of the project to evaluate, as not all of you have direct community contact; however some of this
information could be gathered at networking events which you might hold with recipients of training, contact with parents, schools, partner
agencies etc. As well as your own observations (this is where a diary comes in useful) you could use information obtained from the training
follow up questionnaire (questionnaire 2), if used, and also service users’ questionnaire (questionnaires 3 & 4). f the project does not have any
direct community contact these could be distributed by some of your training recipients or partner organisations. Obviously you need to keep
the evaluation in perspective, and it would be wise to identify a sample as this will prevent you being overwhelmed with questionnaires etc.
What activities have been delivered in the community, by training participants? e.g. Healthy snack scheme etc ? It would be useful to also
include number of activities and participants if known. However, we acknowledge this information may not be easily available for some projects
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Total number of questionnaires Number questionnaire (3&4) distributed______________
distributed and returned up to 31st
October 2007
Number
of
questionnaire
______________
(3&4
Response rates are likely to be lower,
especially as you may be reliant on
others to collect the data on your
behalf
Sex of respondents (Information to Male ________________
be obtained from Questionnaires 3&4)
Female ______________
Employment status
Full time _______________
(Information to be obtained from Part time _____________
Questionnaires 3&4)
I don’t go out to work______
Age of respondents
(Information to be obtained from
Questionnaires 3&4)
_______
17 – 25 _________
26 – 49 _________
50 – 70_________
71 or over _________
16 years or under
Ethnicity
White _____________
(Information to be obtained from
Black Caribbean ___________
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Questionnaires 3&4)
Black African___________
Black other ___________
Indian ____________
Pakistani ___________
Bangladeshi ___________
Chinese ___________
Other group ___________
Number of participants who believed Number
that they had learnt something that
they had not known before? This Yes ______________
information
will
be
from
No_______________
questionnaires 3&4
What were the 3 most important
things that people learnt about diet
and nutrition? Identify main themes
and summarise by using the number
of occurrences e.g. effect of too much
salt n=67
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Following training did participants Number
intend to change their own diet?
Yes ______________
No_______________
Following training did participants Number
intend to change their families diets
Information
available
from Yes ______________
questionnaire 3
No_______________
Not applicable______
What changes did they intend to
make to their diet? This information is
available from questionnaire 3.
Number of responses to each question and option
I intend
to
eat
more of
these
foods
I intend I
do
to
eat intend
less
of change
these
foods
Fruit, Salad and vegetables (not potatoes)
Starchy foods such as bread, potatoes, rice and pasta
91
not
to
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Sugar and sweet foods, such as cakes, biscuits, sweets and soft
drinks
of diet
Fatty or fried foods such as crisps, chips or pies
Fish – not fried
Chicken and other lean meats
Full fat dairy products such as cheese, milk, butter, cream
Did participants change their own Number
diet? This information can be
Yes ______________
obtained from questionnaire 4
No_______________
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Number of responses to each question and option
What changes did they make to their
diet? This information is available
from questionnaire 4.
I now eat I now eat I have not
more of less of these changed
these
foods
consumption
foods
Fruit, Salad and vegetables (not potatoes)
Starchy foods such as bread, potatoes, rice and pasta
Sugar and sweet foods, such as cakes, biscuits, sweets and
soft drinks
of diet
Fatty or fried foods such as crisps, chips or pies
Fish – not fried
Chicken and other lean meats
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Full fat dairy products such as cheese, milk
What other behavioural change has
been observed?
This information could be from your
own observations and discussions, or
extracted from the training follow up
questionnaire (questionnaire 2)
What support has been offered to
community members to help them
make this change?
This could be by you, or by
community food and other workers.
This information could be obtained
from your diaries and questionnaire 2
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Overall, how did community members Number of responses
rate the training? (Information to be
obtained from Questionnaires 3&4)
Very Good ___________
Good ________________
Poor ________________
Very poor ____________
Can’t say _____________
What improvements if
suggested?
any were
(Information to be obtained from
Questionnaires 3&4)
Section 4:Dietitians Reflections
95
Appendix 3 - Evaluation questionnaires used by Dietitians
Dietetics and Nutrition Grant Scheme: Post Course evaluation
questionnaire 1
This scheme is funded by the Welsh Assembly Government. The aim of the scheme is to
enable Community Food Workers and Community Workers to deliver accurate information
about food and nutrition.
EACH PROJECT CAN PERSONALISE HERE
To help us find out what you think about the course you attended we would be grateful if
you could take a few minutes to complete the questionnaire and return it in the box/
envelope provided (customise this according to your project).
Questionnaires are
anonymous. However, the information you provide will be summarised in our interim and
annual reports to the Evaluation Team, commissioned by the Welsh Assembly Government,
based at Glyndwr University Wrexham
Course title
Length of course
Date
First a few questions about the course
1. Did you learn anything about food and nutrition that you had not known before? (Please
tick one)
Yes
No
Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
2. Was there anything, which was not included in the course, which should have been?
Yes
No
Do t k o
3. If yes, what was this? (Please use the space below)
4. As a result of what you learnt on the course are you going to make any changes to your
own diet?
Yes
No
5. If yes, what changes do you intend to make? (Please use the space below)
6. Please tell us below how you will use the information learnt in your own work? (Please
use the space below)
7. In your opinion what was the most important thing you learnt from the course? (Please
use the space below)
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8. Overall, how would you rate the course? (Please tick one only)
Very Good
Good
Poor
Very poor
Ca t sa
Yes
9. Could the course be improved in any way?
No
Do t k o
10. If yes, what would you suggest?
11. What is your role?
A community food worker
School catering professional
A Community worker
Health visitor/ midwife
Nursery/ Early years professional
Something else
Please specify
___________________________
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If you have any other comments, please use the space below?
Thank you for your help
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Dietetics and Nutrition Grant Scheme: Course evaluation
questionnaire 2 (Follow up)
This scheme is funded by the Welsh Assembly Government. The aim of the scheme is enable
Community Food Workers and Community Workers to deliver accurate information about
food and nutrition.
EACH PROJECT CAN PERSONALISE HERE
To help us find out what you think about the course you attended we would be grateful if
you could take a few minutes to complete the questionnaire and return it in the box/
envelope provided (customise this according to your project).
Questionnaires are
anonymous. However, the information you provide will be summarised in our interim and
annual reports to the Evaluation Team, commissioned by the Welsh Assembly Government,
based at NEWI (North East Wales Institute of Higher Education).
Course title
Length of course
Date
First a few questions about the training
1. As a result of attending the course have you made any changes to the way you eat?
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Prifysgol Gly dŵr Wrecsa /Gl dŵr U iversit Wre ha : Dietetic Grant Scheme Evaluation: Final report.
Yes
No
If no, go to Q3
2. If yes, what changes have you made?
3. Please give examples of how you use the information learnt in your own work?
4. Using the space below please list the groups to whom you have given food and nutrition
information? E.g. Mother and babies etc
5. What, if any, problems have you had when passing on food and nutritional information?
6. How was this resolved?
7. Has the food and nutrition skills/information had any impact on the groups you work
with?
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Yes
No
Do t k o
8. Please provide an example of any changes in behaviour, attitude, skills etc in the
groups you work with, that you have noticed, as a result of giving information about
food and nutrition.
9. What is your role?
A community food worker
Nursery or Early years professional
A community worker
School catering professional
Health visitor, Midwife or other health
Some thing else
professional
Please specify
___________________________
10. If you have any other comments please use the space below
Thank you for your help
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Dietetics and Nutrition Grant Scheme: Evaluation questionnaire 3
The scheme is funded by the Welsh Assembly Government. The aim of this is to help
increase community knowledge about diet and nutrition.
EACH PROJECT CAN PERSONALISE HERE
To help us find out what you think about the session(s) you attended we would be grateful if
you could take a few minutes to complete the questionnaire and return it in the box/
envelope provided (customise this according to your project).
Questionnaires are
anonymous. However, the information you provide will be summarised in our interim and
annual reports to the Evaluation Team commissioned by the Welsh Assembly Government
and based at NEWI (North East Wales Institute of Higher Education).
This questionnaire is developed for one-off sessions and very short courses when follow up
would be difficult
This questionnaire is for community members
Name of Course/Session
Date
Length of Course/session
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First a few questions about the course/training session you attended
1. Did you learn anything about food and nutrition that you had not known before? (Please
tick one)
Yes
No
2. In your opinion, what was the most important thing you learnt about food and nutrition?
3. Overall, how would you rate the session/course? (Please tick one only)
Very Good
Good
Poor
Very poor
Ca t sa
4. Could the course be improved in any way?
Yes
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No
Do t k o
5. If yes, please tell us how?
6. Would you say that you currently eat a healthy diet?
Yes
No
Do t k o
7. As a result of the course/training session are you going to make any changes to:What you eat
What your family eats
Yes
Yes
No
No
(if no please go to Q 9)
Does not apply
8. Please look at the list of foods below and indicate for each, by ticking the box, where you
intend to make changes
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I intend to I intend to I do not
eat
more eat less of intend
of
these these
foods
change
foods
Fruit, Salad and vegetables (not potatoes)
Starchy foods such as bread, potatoes, rice and pasta
Sugar and sweet foods, such as cakes, biscuits, sweets and soft drinks
Fatty or fried foods such as crisps, chips or pies
Fish – not fried
Chicken and other lean meats
Full fat dairy products such as cheese, milk
Any other changes not listed above
Finally a few questions about your self
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9. Are you?
10. Do you work?
Male
Full time
Female
Part time
I do t go out to o k
11. In which age group are you?
16 years or under ❒
17 – 25 ❒
26 – 49 ❒
50 - 70❒
71 or over ❒
13 Which best describes you?
White
Black Caribbean
Black African
Black other
Indian
Pakistani
Bangladeshi
Chinese
Other group
Please specify_____________
Thank you for your help, now please return the questionnaire using the box/ envelope
provided
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Dietetics and Nutrition Grant Scheme: Evaluation questionnaire 4
The scheme is funded by the Welsh Assembly Government, the aim of which is to help
increase community knowledge about food and nutrition.
EACH PROJECT CAN PERSONALISE HERE
To help us find out what you think about the course you attended we would be grateful if
you could take a few minutes to complete the questionnaire and return it in the box/
envelope provided (customise this according to your project).
Questionnaires are
anonymous. However, the information you provide will be summarised in our interim and
annual reports to the Evaluation Team commissioned by the Welsh Assembly Government
and based at NEWI (North East Wales Institute of Higher Education).
This questionnaire has been developed for courses of a few weeks in duration, such as
Cook and Eat etc when some behavioural change may have occurred. It is suggested that
this is given out at the last session
This questionnaire is for community members
Name of Course/Session
Date
Length of Course/session
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First a few questions about the course/training session you attended
1. Did you learn anything about food and nutrition that you had not known before? (Please
tick one)
Yes
No
2. In your opinion, what was the most important thing you learnt?
3. Overall, how would you rate the course? (Please tick one only)
Very Good
Good
Poor
Very poor
Ca t sa
4. Could the course be improved in any way? (Please tick one only)
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Yes
No
Do t k o
5. If yes, please tell us how?
6. As a result of the course/training session have you made any changes to:-
What you eat
What your family eats
Yes
Yes
No
No
Does not apply
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7. Please look at the list of foods below and indicate for each, by ticking the box, where you
have made changes to the way to eat since attending the course
I now eat I now eat I have not
more
of less
of made any
these
these
foods
foods
changes
Fruit, Salad and vegetables (not potatoes)
Starchy foods such as bread, potatoes, rice and pasta
Sugar and sweet foods, such as cakes, biscuits, sweets and soft drinks
Fatty or fried foods such as crisps, chips or pies
Fish – not fried
Chicken and other lean meats
Full fat dairy products such as cheese, milk
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Any other changes not listed above
8. Do you eat more healthily now than before starting the course?
Yes
No
Do t k o
Finally a few questions about your self
Are you?
Do you work?
Male
Full time
Female
Part time
I do t go out to o k
In which age group are you?
16 years or under ❒
17 – 25 ❒
26 – 49 ❒
50 - 70❒
71 or over ❒
Which best describes you?
White
Black Caribbean
Black African
Black other
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Indian
Pakistani
Bangladeshi
Chinese
Other group
Please specify_____________
Thank you for your help, now please return the questionnaire using the box/ envelope
provided
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Appendix 4 - Different models of course delivery
Duration of
training course
Frequency of sessions (e.g.
once per week, one-off etc)
Duration of
training course
Frequency of sessions (e.g.
once per week, one-off etc)
3 full days
Approx one per fortnight
3 consecutive days
1 day per month
6 weeks
1 x 4hr session per week
5 half days over 6 weeks
Over a 10 week
period
1 day every other week
1x 2 hour session weekly
12 weeks
10 session x 2 hrs over the
period
2 days
Over 4 weeks
2 consecutive days
4 weeks
Days and 2x2 hr sessions
1 day per week
1 evenings per week
4 half days
5 Weeks
Half day per week
2 x 2 hour session per week
1x 2 hour session per week
1 day per week
3 weeks
2 half days per week
1 full day per week
2 days and one half day
2 weeks
Five session per week
2 days
1 week
5 Consecutive days
2.5 weeks
2 hr session every other day
8 weeks
1x 2.5 hour session
7 weeks
1 day per week
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